Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | PT010825 | GA |
Y | 2251G0304X | Physical Therapist - Geriatrics | 9283 | TN |
NPI | 1073058210 |
---|---|
Provider Name | Deandra Thompson |
First Address | Hixson, TN 37343-1772 |
Second Address | Hixson, TN 37343-1772 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/12/2016 |
Last Update Date | 26/12/2016 |