Provider Demographics
NPI:1083321285
Name:THOMPSON, MARYCONNOR TACY (WHNP)
Entity type:Individual
Prefix:
First Name:MARYCONNOR
Middle Name:TACY
Last Name:THOMPSON
Suffix:
Gender:
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 WOLVERINE ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1201
Mailing Address - Country:US
Mailing Address - Phone:888-875-7820
Mailing Address - Fax:
Practice Address - Street 1:3825 WOLVERINE ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1201
Practice Address - Country:US
Practice Address - Phone:888-875-7820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-28
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN287283163W00000X
OR10025826363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse