Provider Demographics
NPI:1528495355
Name:THOMPSON, NEVADA BENNETT
Entity type:Individual
Prefix:MRS
First Name:NEVADA
Middle Name:BENNETT
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 1:2622 W MAIN ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-3967
Mailing Address - Country:US
Mailing Address - Phone:406-587-9679
Mailing Address - Fax:
Practice Address - Street 1:2622 W MAIN ST
Practice Address - Street 2:SUITE D
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59718-3967
Practice Address - Country:US
Practice Address - Phone:406-587-9679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-11
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-908172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker