Provider Demographics
NPI:1295933646
Name:THOMPSON, MAZILYN MARJORIE
Entity type:Individual
Prefix:
First Name:MAZILYN
Middle Name:MARJORIE
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 1:3342 EASTCHESTER RD
Mailing Address - Street 2:2
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-2705
Mailing Address - Country:US
Mailing Address - Phone:917-940-7780
Mailing Address - Fax:
Practice Address - Street 1:3342 EASTCHESTER RD
Practice Address - Street 2:2
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-2705
Practice Address - Country:US
Practice Address - Phone:917-940-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282395-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02879156Medicaid