Provider Demographics
NPI:1104578418
Name:THOMPSON, FALLON
Entity type:Individual
Prefix:
First Name:FALLON
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E JUNEAU PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8269
Mailing Address - Country:US
Mailing Address - Phone:918-289-3697
Mailing Address - Fax:
Practice Address - Street 1:1819 E 19TH ST STE 500
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5429
Practice Address - Country:US
Practice Address - Phone:918-744-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0136311163W00000X
OK215536363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse