Healthcare Provider Details

I. General information

NPI: 1790141083
Provider Name (Legal Business Name): VICTORIA G THOMPSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2016
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 WENTZVILLE PKWY
WENTZVILLE MO
63385-3408
US

IV. Provider business mailing address

1520 WENTZVILLE PKWY
WENTZVILLE MO
63385-3408
US

V. Phone/Fax

Practice location:
  • Phone: 636-497-4060
  • Fax:
Mailing address:
  • Phone: 636-497-4060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2015043226
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2015043226
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: