Provider Demographics
NPI:1467182915
Name:THOMPSON, ANGELINA LEE (NAC)
Entity Type:Individual
Prefix:
First Name:ANGELINA
Middle Name:LEE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:NAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 N EDISON ST APT D102
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1579
Mailing Address - Country:US
Mailing Address - Phone:509-578-9109
Mailing Address - Fax:
Practice Address - Street 1:50 CANYON ST
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-9420
Practice Address - Country:US
Practice Address - Phone:509-578-9109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-15
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANC60730833376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA604738598OtherUNIFIED BUSINESS IDENTIFIER