Provider Demographics
NPI:1922649250
Name:THOMPSON, IDA
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:
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 1:136 KANE ST
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-2195
Mailing Address - Country:US
Mailing Address - Phone:860-985-4514
Mailing Address - Fax:
Practice Address - Street 1:136 KANE ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-2195
Practice Address - Country:US
Practice Address - Phone:860-985-4514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide