Provider Demographics
NPI:1790197283
Name:GAINES-THOMPSON, VIVIAN (NP)
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:
Last Name:GAINES-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:PO BOX 740015
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0015
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:1825 ROCKBRIDGE RD STE 15B
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3306
Practice Address - Country:US
Practice Address - Phone:470-444-3134
Practice Address - Fax:470-276-4370
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28103222A363LF0000X
GAGAA-NP000530363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INF0614489OtherBOARD CERTIFICATION