Provider Demographics
NPI:1609438159
Name:THOMPSON, MAMIE ALICIA (RD)
Entity Type:Individual
Prefix:MRS
First Name:MAMIE
Middle Name:ALICIA
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N MONTE VISTA ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4657
Mailing Address - Country:US
Mailing Address - Phone:580-421-1516
Mailing Address - Fax:580-272-1618
Practice Address - Street 1:430 N MONTE VISTA ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4657
Practice Address - Country:US
Practice Address - Phone:580-421-1516
Practice Address - Fax:580-272-1618
Is Sole Proprietor?:No
Enumeration Date:2019-07-05
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK769133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered