Healthcare Provider Details

I. General information

NPI: 1992170435
Provider Name (Legal Business Name): NICOLA THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9363 WEDGEWOOD DR
TAMARAC FL
33321-3567
US

IV. Provider business mailing address

9363 WEDGEWOOD DR
TAMARAC FL
33321-3567
US

V. Phone/Fax

Practice location:
  • Phone: 954-907-5125
  • Fax:
Mailing address:
  • Phone: 954-907-5125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number213224
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: