Provider Demographics
NPI:1093056400
Name:THOMPSON, TAYANA
Entity Type:Individual
Prefix:MRS
First Name:TAYANA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAYANA
Other - Middle Name:
Other - Last Name:BONHOMME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 TILLARY ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3010
Mailing Address - Country:US
Mailing Address - Phone:917-830-5239
Mailing Address - Fax:
Practice Address - Street 1:200 TILLARY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3010
Practice Address - Country:US
Practice Address - Phone:917-830-5239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYXB12968XMedicaid