Basic Information
Provider Information | |||||||||
NPI: | 1841678786 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THORNTON | ||||||||
FirstName: | BRIANNE | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOHLKE | ||||||||
OtherFirstName: | BRIANNE | ||||||||
OtherMiddleName: | C. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7974 UW HEALTH CT | ||||||||
Address2: |   | ||||||||
City: | MIDDLETON | ||||||||
State: | WI | ||||||||
PostalCode: | 535625531 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088295485 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4602 EASTPARK BLVD | ||||||||
Address2: |   | ||||||||
City: | MADISON | ||||||||
State: | WI | ||||||||
PostalCode: | 537182002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6088905500 | ||||||||
FaxNumber: | 6083637395 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2015 | ||||||||
LastUpdateDate: | 12/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2728-29 | WI | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.