Provider Demographics
NPI:1679813778
Name:THOMPSON, DWAYNE (LVN, CNA)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:LVN, CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 8321
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91912-8321
Mailing Address - Country:US
Mailing Address - Phone:714-278-7622
Mailing Address - Fax:888-316-1604
Practice Address - Street 1:2892 N BELLFLOWER BLVD
Practice Address - Street 2:SUITE 281
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-1125
Practice Address - Country:US
Practice Address - Phone:714-614-5387
Practice Address - Fax:888-316-1604
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA390200000X
CA691103164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program