Healthcare Provider Details

I. General information

NPI: 1205121498
Provider Name (Legal Business Name): TERRY L THOMPSON RN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CHANNING WAY STE A205
IDAHO FALLS ID
83404-7586
US

IV. Provider business mailing address

PO BOX 277381
ATLANTA GA
30384-7381
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4580
  • Fax: 208-535-4520
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-1070A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: