Provider Demographics
NPI:1285405266
Name:THOMPSON, JULISSA NICHEAL
Entity type:Individual
Prefix:
First Name:JULISSA
Middle Name:NICHEAL
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 1:4079 ELY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-2207
Mailing Address - Country:US
Mailing Address - Phone:646-241-0562
Mailing Address - Fax:
Practice Address - Street 1:4079 ELY AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2207
Practice Address - Country:US
Practice Address - Phone:646-241-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-305742174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN