Healthcare Provider Details

I. General information

NPI: 1407209299
Provider Name (Legal Business Name): TRACI THORNSBURY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 LOGAN ST STE A
WILLIAMSON WV
25661-3606
US

IV. Provider business mailing address

PO BOX 2080
WILLIAMSON WV
25661-2080
US

V. Phone/Fax

Practice location:
  • Phone: 304-236-5902
  • Fax:
Mailing address:
  • Phone: 304-236-5902
  • Fax: 855-487-4047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number92307
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number92307
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: