Provider Demographics
NPI:1154480804
Name:THOMSEN, MARY E (CERTIFIED FITTER FOR)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:THOMSEN
Suffix:
Gender:F
Credentials:CERTIFIED FITTER FOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 CHERRY OAK TRAIL
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465
Mailing Address - Country:US
Mailing Address - Phone:601-543-0268
Mailing Address - Fax:
Practice Address - Street 1:173 CHERRY OAK TRAIL
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465
Practice Address - Country:US
Practice Address - Phone:601-543-0268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0440560Medicaid
MS0440560Medicaid