Healthcare Provider Details

I. General information

NPI: 1851568315
Provider Name (Legal Business Name): MRS. MYSTIC MICHELLE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 E BROADWAY ST
NORTH LITTLE ROCK AR
72114-6344
US

IV. Provider business mailing address

3223 E BROADWAY ST
NORTH LITTLE ROCK AR
72114-6344
US

V. Phone/Fax

Practice location:
  • Phone: 501-945-5544
  • Fax: 501-945-5546
Mailing address:
  • Phone: 501-945-5544
  • Fax: 501-945-5546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR67979
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: