Provider Demographics
NPI:1053532978
Name:THORNBLAD, DONNA MARGARET (LCM)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MARGARET
Last Name:THORNBLAD
Suffix:
Gender:F
Credentials:LCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 NORTH MOUNTAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414
Mailing Address - Country:US
Mailing Address - Phone:801-782-3798
Mailing Address - Fax:
Practice Address - Street 1:237 26TH STREET
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401
Practice Address - Country:US
Practice Address - Phone:801-625-3767
Practice Address - Fax:801-625-3896
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT876000308007Medicaid