Provider Demographics
NPI:1043807241
Name:THOMPSON, TRACEY ANN
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:ANN
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 1:5215 W 139TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1954
Mailing Address - Country:US
Mailing Address - Phone:650-556-3321
Mailing Address - Fax:
Practice Address - Street 1:5215 W 139TH ST
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-1954
Practice Address - Country:US
Practice Address - Phone:650-556-3321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2482415163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice