Provider Demographics
NPI:1285173476
Name:THOMPSON, PATRICIA
Entity type:Individual
Prefix:MISS
First Name:PATRICIA
Middle Name:
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 1:2807 HWY 138 LAKE SPIVEY
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6087
Mailing Address - Country:US
Mailing Address - Phone:678-549-3355
Mailing Address - Fax:
Practice Address - Street 1:2465 LAKE ERMA DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-6087
Practice Address - Country:US
Practice Address - Phone:678-549-3355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACOL-0018051744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management