Provider Demographics
NPI:1710997473
Name:THOMPSON, SHIRLEY J (CNM)
Entity Type:Individual
Prefix:MS
First Name:SHIRLEY
Middle Name:J
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 905
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-0905
Mailing Address - Country:US
Mailing Address - Phone:802-748-7300
Mailing Address - Fax:802-748-7321
Practice Address - Street 1:1315 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9210
Practice Address - Country:US
Practice Address - Phone:802-748-7300
Practice Address - Fax:802-748-7321
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704125240367A00000X
VT042-0006555367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3080101Medicaid
VT1021133Medicaid
VT1021133Medicaid