=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588313589
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATALIE THACKER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2022
-----------------------------------------------------
Last Update Date | 03/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 CLIFTON ST
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62234-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-795-0097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 CLIFTON ST
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62234-4214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-795-0097
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------