MEDICARE: KIMBERLY AILENE THOMPSON LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	146N00000X	Basic Emergency Medical Technician	6292-2352	IN
2	164W00000X	Licensed Practical Nurse	27073046A	IN
3	164W00000X	Licensed Practical Nurse	4703096215	MI

General Provider Information

NPI Number	:	1841646072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY AILENE THOMPSON LPN

Provider Business Mailing Address
First Line	:	1321 CLARA AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-3517
Country	:	US
Telephone Number	:	231-215-6960
Fax Number	:

Provider Business Practice Location Address
First Line	:	1321 CLARA AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-3517
Country	:	US
Telephone Number	:	231-215-6960
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/06/2016
Last Update Date	:	05/06/2016

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