Healthcare Provider Details

I. General information

NPI: 1245987858
Provider Name (Legal Business Name): MARYGRACE THOMPSON LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2022
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31323 VERDE MARE DR
WINCHESTER CA
92596-8362
US

IV. Provider business mailing address

31323 VERDE MARE DR
WINCHESTER CA
92596-8362
US

V. Phone/Fax

Practice location:
  • Phone: 760-459-9540
  • Fax:
Mailing address:
  • Phone: 760-459-9540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number263350
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: