Healthcare Provider Details

I. General information

NPI: 1205754702
Provider Name (Legal Business Name): KAJA THOMPSON
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2429 SPUR LN
CONCORD NC
28027-7912
US

IV. Provider business mailing address

350 5TH AVE
NEW YORK NY
10118-0110
US

V. Phone/Fax

Practice location:
  • Phone: 704-425-3710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL0009989
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: