Provider Demographics
NPI:1912987926
Name:THOMPSON, MITZI B (NP)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:B
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 NW STEWART PKWY
Mailing Address - Street 2:STE 240
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1516
Mailing Address - Country:US
Mailing Address - Phone:541-677-6111
Mailing Address - Fax:541-677-6140
Practice Address - Street 1:2460 NW STEWART PARKWAY
Practice Address - Street 2:SUITE 104
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1516
Practice Address - Country:US
Practice Address - Phone:541-677-4463
Practice Address - Fax:541-677-3379
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201505556NP-PP363LW0102X
TNAPN 0000005657363LW0102X
TNRN0000055333163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3905311OtherMEDICARE-TENNCARE
OR500695863Medicaid
TN3905311Medicaid
TN3905311OtherMEDICARE-TENNCARE
ORR184865Medicare PIN