Healthcare Provider Details

I. General information

NPI: 1649811456
Provider Name (Legal Business Name): LISA GAILE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 DUPONT CIR STE 226
ST MATTHEWS KY
40207-4847
US

IV. Provider business mailing address

4010 DUPONT CIR
LOUISVILLE KY
40207-4812
US

V. Phone/Fax

Practice location:
  • Phone: 502-896-8006
  • Fax:
Mailing address:
  • Phone: 502-896-8006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: