Provider Demographics
NPI:1558679324
Name:THOMPSON, PAULETTE PURDY
Entity Type:Individual
Prefix:MRS
First Name:PAULETTE
Middle Name:PURDY
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1823 LONGWOOD KEY DR N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-3474
Mailing Address - Country:US
Mailing Address - Phone:904-757-9173
Mailing Address - Fax:904-757-4264
Practice Address - Street 1:1823 LONGWOOD KEY DR N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-3474
Practice Address - Country:US
Practice Address - Phone:904-757-9173
Practice Address - Fax:904-757-4264
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693572996Medicaid
FL693572901Medicaid
FL693572902Medicaid