Provider Demographics
NPI:1316536063
Name:THACKER, KRISTEN LEIGH (RN)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LEIGH
Last Name:THACKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704-1334
Mailing Address - Country:US
Mailing Address - Phone:740-357-9155
Mailing Address - Fax:
Practice Address - Street 1:330 25TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7820
Practice Address - Country:US
Practice Address - Phone:066-329-8588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.162430101YA0400X
OHCDCA.174239101YA0400X
WV98443163WP0808X
KY98443163W00000X
OHRN.482139163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRN.482139OtherOHIO NURSING
OH0430382Medicaid