Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 702394 | TX |
NPI | 1003249558 |
---|---|
Provider Name | Sally A Thompson |
First Address | Texarkana, TX 75503-0711 |
Second Address | Texarkana, TX 75503-0711 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2013 |
Last Update Date | 24/04/2014 |