=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710347059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA THORNBERRY PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2016
-----------------------------------------------------
Last Update Date | 08/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 RANDALLIA DR
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46805-4638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-344-4035
-----------------------------------------------------
Fax | 260-969-9272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6435 W JEFFERSON BLVD PMB 109
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46804-6203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-344-4035
-----------------------------------------------------
Fax | 260-969-9272
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | RN.372896
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 71007032A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------