Provider Demographics
NPI:1003012287
Name:THOMASON, BRENDA (APRN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:THOMASON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 DEBORAH DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2111
Mailing Address - Country:US
Mailing Address - Phone:318-323-5688
Mailing Address - Fax:
Practice Address - Street 1:3510 MAGNOLIA CV
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2372
Practice Address - Country:US
Practice Address - Phone:318-323-1100
Practice Address - Fax:318-323-1161
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1664821Medicaid
LA1442399OtherTDK AMC GROUP AID PROVIDE