Provider Demographics
NPI:1003467457
Name:THOMPSON, SHUNTAIL
Entity Type:Individual
Prefix:
First Name:SHUNTAIL
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 DUMONT BLVD # 2020C
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-4265
Mailing Address - Country:US
Mailing Address - Phone:870-549-8865
Mailing Address - Fax:
Practice Address - Street 1:1100 DUMONT BLVD # 2020C
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-4265
Practice Address - Country:US
Practice Address - Phone:870-549-8865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant