Provider Demographics
NPI:1053606152
Name:THORN, TAMARA KAY (CNP)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:KAY
Last Name:THORN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:
Practice Address - Street 1:5348 LAMME RD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439-3215
Practice Address - Country:US
Practice Address - Phone:937-534-4600
Practice Address - Fax:937-522-8799
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA,12381-NP363LP2300X, 363LP2300X
OHAPRN.CNP.12381363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH013688OtherMEDICARE - OHIO
OH0051257Medicaid