Provider Demographics
NPI:1831265107
Name:THACKER, MECHELE L (APRN-CNP)
Entity type:Individual
Prefix:MS
First Name:MECHELE
Middle Name:L
Last Name:THACKER
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:MECHELE
Other - Middle Name:L
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN CNP
Mailing Address - Street 1:415 MORRIS ST 201
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1853
Mailing Address - Country:US
Mailing Address - Phone:304-388-7700
Mailing Address - Fax:304-388-7755
Practice Address - Street 1:415 MORRIS ST
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1842
Practice Address - Country:US
Practice Address - Phone:304-388-7700
Practice Address - Fax:304-388-7755
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV47680363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810007981Medicaid
WV3810007981Medicaid
WVWV1278AMedicare PIN
WV22121Medicare PIN