Healthcare Provider Details

I. General information

NPI: 1215553540
Provider Name (Legal Business Name): MISTI THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 29TH ST NE
CEDAR RAPIDS IA
52402-3452
US

IV. Provider business mailing address

1825 29TH ST NE
CEDAR RAPIDS IA
52402-3452
US

V. Phone/Fax

Practice location:
  • Phone: 319-362-6994
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number074472
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: