Healthcare Provider Details

I. General information

NPI: 1174644462
Provider Name (Legal Business Name): MARTHA CHARLENE THOMPSON L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1280 ATHENS ST
GAINESVILLE GA
30507-7000
US

IV. Provider business mailing address

1280 ATHENS ST
GAINESVILLE GA
30507-7000
US

V. Phone/Fax

Practice location:
  • Phone: 770-535-5875
  • Fax: 770-531-4544
Mailing address:
  • Phone: 770-535-5875
  • Fax: 770-531-4544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberLD000892
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: