Provider Demographics
NPI:1467761692
Name:THOMPSON, SHANEQA JORDAN (LPN)
Entity Type:Individual
Prefix:MS
First Name:SHANEQA
Middle Name:JORDAN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7005 GLEN VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4278
Mailing Address - Country:US
Mailing Address - Phone:313-808-3314
Mailing Address - Fax:
Practice Address - Street 1:7005 GLEN VALLEY WAY
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-4278
Practice Address - Country:US
Practice Address - Phone:313-808-3314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN082534164W00000X
OHPN115400164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse