Healthcare Provider Details

I. General information

NPI: 1356336457
Provider Name (Legal Business Name): ANGELA RENEE THOMPSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 SELLERS RD
SHALLOTTE NC
28470-3405
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-4441
  • Fax: 910-754-5307
Mailing address:
  • Phone: 910-754-4441
  • Fax: 910-754-5307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number200001310
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: