Provider Demographics
NPI:1376679878
Name:THOMPSON, TASHA (RN)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 TULIP AVE
Mailing Address - Street 2:PO BOX 20838
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-1925
Mailing Address - Country:US
Mailing Address - Phone:917-862-5215
Mailing Address - Fax:718-347-4643
Practice Address - Street 1:635 RIVERSIDE DR APT 5D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-7118
Practice Address - Country:US
Practice Address - Phone:917-862-5215
Practice Address - Fax:718-347-4643
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY519821163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02750934Medicaid