Provider Demographics
NPI:1952153033
Name:THOMPSON, MANDISSA SARAFINA
Entity Type:Individual
Prefix:
First Name:MANDISSA
Middle Name:SARAFINA
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 1:17 CYPRESS LN
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3004
Mailing Address - Country:US
Mailing Address - Phone:215-087-0799
Mailing Address - Fax:
Practice Address - Street 1:17 CYPRESS LN
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3004
Practice Address - Country:US
Practice Address - Phone:215-087-0799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman