Provider Demographics
NPI:1164079828
Name:THOMPSON, IVY E (CFNP)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:E
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:
Other - Last Name:REGISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:411 MORGANTOWN ST
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1095
Mailing Address - Country:US
Mailing Address - Phone:304-329-0555
Mailing Address - Fax:304-329-0556
Practice Address - Street 1:630 FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-5104
Practice Address - Country:US
Practice Address - Phone:304-534-8931
Practice Address - Fax:681-404-6120
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-19
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV104266363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1164079828Medicaid