Provider Demographics
NPI:1386196996
Name:THOMPSON, MAKENZIE
Entity Type:Individual
Prefix:MRS
First Name:MAKENZIE
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MAKENZIE
Other - Middle Name:
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:202 GUYANDOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:MULLENS
Mailing Address - State:WV
Mailing Address - Zip Code:25882-1308
Mailing Address - Country:US
Mailing Address - Phone:304-294-6800
Mailing Address - Fax:
Practice Address - Street 1:149 MCINTOSH ST
Practice Address - Street 2:
Practice Address - City:GHENT
Practice Address - State:WV
Practice Address - Zip Code:25843-1805
Practice Address - Country:US
Practice Address - Phone:304-673-0844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-30
Last Update Date:2020-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV92290163WM0705X
WV106985363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical