Provider Demographics
NPI:1609384197
Name:THOMPSON, PANCHANOK CHUMPUMUD (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:PANCHANOK
Middle Name:CHUMPUMUD
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5145 BREEZE HOLLOW CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-4257
Mailing Address - Country:US
Mailing Address - Phone:817-913-9624
Mailing Address - Fax:
Practice Address - Street 1:1643 LANCASTER DR STE 305
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3593
Practice Address - Country:US
Practice Address - Phone:817-778-0191
Practice Address - Fax:817-421-2940
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135936363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty