Provider Demographics
NPI:1598093072
Name:THOMPSON, TISHAMBAY DENISE (NP)
Entity Type:Individual
Prefix:
First Name:TISHAMBAY
Middle Name:DENISE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TI
Other - Middle Name:D
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:13921 HOLLOW WIND WAY UNIT 101
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-6057
Mailing Address - Country:US
Mailing Address - Phone:281-770-9577
Mailing Address - Fax:
Practice Address - Street 1:5372 FALLOWATER LN STE 200
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0909
Practice Address - Country:US
Practice Address - Phone:216-898-8399
Practice Address - Fax:216-898-8455
Is Sole Proprietor?:No
Enumeration Date:2009-11-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC198916163W00000X
VA0024177247363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse