Basic Information
| Provider Information | |||||||||
| NPI: | 1548781727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THORNBER | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4910 DIRECTORS PL STE 350 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921213834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583467171 | ||||||||
| FaxNumber: | 8584537314 | ||||||||
| Practice Location | |||||||||
| Address1: | 4910 DIRECTORS PL STE 350 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921213834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583467171 | ||||||||
| FaxNumber: | 8584537314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZX2200X | 14-0817 | CA | Y |
No ID Information.