Healthcare Provider Details

I. General information

NPI: 1386890812
Provider Name (Legal Business Name): MISTY DANIELLE THOMPSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2008
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 CUMBERLAND FALLS HWY STE D141
CORBIN KY
40701-2796
US

IV. Provider business mailing address

210 BLACK GOLD BLVD SUITE 212
HAZARD KY
41701-2620
US

V. Phone/Fax

Practice location:
  • Phone: 606-528-5527
  • Fax: 606-526-9687
Mailing address:
  • Phone: 606-439-0326
  • Fax: 606-439-0475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number655
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number3528
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: