Provider Demographics
NPI:1700492683
Name:THOMPSON, CARLY ELIZABETH
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ELIZABETH
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 1:2455 SPRINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-8957
Mailing Address - Country:US
Mailing Address - Phone:517-582-2336
Mailing Address - Fax:
Practice Address - Street 1:3322 E BELTLINE CT NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9480
Practice Address - Country:US
Practice Address - Phone:616-226-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704298713363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily