Healthcare Provider Details

I. General information

NPI: 1720067457
Provider Name (Legal Business Name): COLETTE THOMPSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 UNION POINT ST
LEXINGTON GA
30648-2303
US

IV. Provider business mailing address

PO BOX 459
COLBERT GA
30628-0459
US

V. Phone/Fax

Practice location:
  • Phone: 706-743-8171
  • Fax: 706-743-3000
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR607355
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: