Provider Demographics
NPI:1336896687
Name:THOMPSON, MATTHEW HAL (APRN)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:HAL
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2435 KENILWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-2753
Mailing Address - Country:US
Mailing Address - Phone:386-334-0061
Mailing Address - Fax:
Practice Address - Street 1:2435 KENILWORTH AVE
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-2753
Practice Address - Country:US
Practice Address - Phone:386-334-0061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-07
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11016871363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health