Provider Demographics
NPI:1386011252
Name:THOMPSON, BETH ANN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 COLONY BAY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61109-2560
Mailing Address - Country:US
Mailing Address - Phone:779-368-0757
Mailing Address - Fax:
Practice Address - Street 1:3413 COLONY BAY DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-2560
Practice Address - Country:US
Practice Address - Phone:779-368-0757
Practice Address - Fax:779-368-0758
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.002784363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400250010Medicare PIN