Provider Demographics
NPI:1811185333
Name:THOMPSON, MERVIANNA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:MERVIANNA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 ALTO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2406
Mailing Address - Country:US
Mailing Address - Phone:505-982-4425
Mailing Address - Fax:505-982-8440
Practice Address - Street 1:818 CAMINO SIERRA VIS
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3018
Practice Address - Country:US
Practice Address - Phone:505-988-1742
Practice Address - Fax:505-780-8611
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMTL02117363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM68971567Medicaid
TXTXB106001OtherMEDICARE PTAN