Provider Demographics
NPI:1447631692
Name:THORNTON, CHARLES (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:THORNTON
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 AL HIGHWAY 157 STE 303
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35058-1273
Mailing Address - Country:US
Mailing Address - Phone:256-775-1090
Mailing Address - Fax:256-736-6228
Practice Address - Street 1:503 CLARK ST NE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-1921
Practice Address - Country:US
Practice Address - Phone:256-739-4131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-113277363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALE869Medicare PIN