Provider Demographics
NPI:1770214165
Name:THOMPSON, NICOLE ANNA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNA
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 1:3001 QUAIL SPRINGS PKWY FL 5
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-2640
Mailing Address - Country:US
Mailing Address - Phone:405-666-9860
Mailing Address - Fax:405-666-9876
Practice Address - Street 1:750 SW 19TH ST STE A
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2974
Practice Address - Country:US
Practice Address - Phone:405-666-9860
Practice Address - Fax:405-666-9876
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4829363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant