Basic Information
| Provider Information | |||||||||
| NPI: | 1831265107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THACKER | ||||||||
| FirstName: | MECHELE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN-CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WARREN | ||||||||
| OtherFirstName: | MECHELE | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN CNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 415 MORRIS ST 201 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887700 | ||||||||
| FaxNumber: | 3043887755 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 MORRIS ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887700 | ||||||||
| FaxNumber: | 3043887755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 05/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 47680 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363L00000X | 47680 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3810007981 | 05 | WV | MEDICAID |