Provider Demographics
NPI:1669006789
Name:THOMPSON, BRENNA PAIGE
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:PAIGE
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 1:357 TIPPERARY LOOP
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-1677
Mailing Address - Country:US
Mailing Address - Phone:609-271-9077
Mailing Address - Fax:
Practice Address - Street 1:357 TIPPERARY LOOP
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-1677
Practice Address - Country:US
Practice Address - Phone:609-271-9077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist