=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710348453
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KORY THORNBURG CNP, FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2016
-----------------------------------------------------
Last Update Date | 03/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4445 KENT RD
-----------------------------------------------------
City | STOW
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44224-4332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-678-0040
-----------------------------------------------------
Fax | 330-673-4554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 230 QUADRAL DR STE B
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-8375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-336-3280
-----------------------------------------------------
Fax | 330-336-5325
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | RN.347169-1
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------