Provider Demographics
NPI:1487660353
Name:THOMPSON, BRENDA M (FNP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:M
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 S MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0163
Mailing Address - Country:US
Mailing Address - Phone:912-705-5483
Mailing Address - Fax:
Practice Address - Street 1:755 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0130
Practice Address - Country:US
Practice Address - Phone:912-705-2273
Practice Address - Fax:912-705-2274
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN070005363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ54580Medicare UPIN
GA50BBJTWMedicare ID - Type Unspecified