Provider Demographics
NPI:1609952688
Name:THOMPSON, JOHNETTA GIGI (NP)
Entity Type:Individual
Prefix:
First Name:JOHNETTA
Middle Name:GIGI
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 RIVERWALK
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-9014
Mailing Address - Country:US
Mailing Address - Phone:770-914-0692
Mailing Address - Fax:
Practice Address - Street 1:3240 S COBB DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4194
Practice Address - Country:US
Practice Address - Phone:770-433-3447
Practice Address - Fax:770-433-3448
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN153018363L00000X
LARN 119790 AP05291363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3A466D078Medicare PIN