Provider Demographics
NPI:1922007475
Name:THOMPSON, COLLEEN A (ARNP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:A
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4196 W US HIGHWAY 90
Mailing Address - Street 2:SUITE 105
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-8833
Mailing Address - Country:US
Mailing Address - Phone:386-243-8474
Mailing Address - Fax:386-438-5945
Practice Address - Street 1:4196 W US HIGHWAY 90
Practice Address - Street 2:STE 105
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8833
Practice Address - Country:US
Practice Address - Phone:386-243-8474
Practice Address - Fax:386-438-5945
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2667852363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306015200Medicaid
P82895Medicare UPIN
FL306015200Medicaid
FLU0290XMedicare PIN