Healthcare Provider Details

I. General information

NPI: 1790977205
Provider Name (Legal Business Name): MARY JANE THOMPSON CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2007
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 CREEK RD
CONNEAUT OH
44030-3018
US

IV. Provider business mailing address

6100 ROCKSIDE WOODS BLVD N SUITE 425
INDEPENDENCE OH
44131-2366
US

V. Phone/Fax

Practice location:
  • Phone: 440-813-5785
  • Fax:
Mailing address:
  • Phone: 216-643-2780
  • Fax: 216-524-0111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1281636
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: