Provider Demographics
NPI:1669935169
Name:THOMPSON, NICOLE M
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:M
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 1:202 JUNIPER CIR
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-2950
Mailing Address - Country:US
Mailing Address - Phone:856-812-1689
Mailing Address - Fax:
Practice Address - Street 1:4 EVES DR STE A100
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3126
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002854002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer