Provider Demographics
NPI:1316409329
Name:THOMPSON, SHANICA D
Entity Type:Individual
Prefix:
First Name:SHANICA
Middle Name:D
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 1:213 HODGE ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-2721
Mailing Address - Country:US
Mailing Address - Phone:318-733-2113
Mailing Address - Fax:
Practice Address - Street 1:213 HODGE ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-2721
Practice Address - Country:US
Practice Address - Phone:318-733-2113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009392062171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor