Provider Demographics
NPI:1407418197
Name:THOMPSON, GRETTA LAVONNE (LINCENSED VOCATIONAL)
Entity Type:Individual
Prefix:
First Name:GRETTA
Middle Name:LAVONNE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LINCENSED VOCATIONAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 E 43RD ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-3228
Mailing Address - Country:US
Mailing Address - Phone:323-561-5899
Mailing Address - Fax:
Practice Address - Street 1:4450 W CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90304-1504
Practice Address - Country:US
Practice Address - Phone:310-671-9247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN188467164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVN188467Medicaid