Provider Demographics
NPI:1841646072
Name:THOMPSON, KIMBERLY AILENE (LPN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:AILENE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 CLARA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3517
Mailing Address - Country:US
Mailing Address - Phone:231-215-6960
Mailing Address - Fax:
Practice Address - Street 1:1321 CLARA AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3517
Practice Address - Country:US
Practice Address - Phone:231-215-6960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-06
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN6292-2352146N00000X
IN27073046A164W00000X
MI4703096215164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic