Healthcare Provider Details

I. General information

NPI: 1912987926
Provider Name (Legal Business Name): MITZI B THOMPSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 NW STEWART PARKWAY SUITE 104
ROSEBURG OR
97471-1516
US

IV. Provider business mailing address

2460 NW STEWART PKWY STE 240
ROSEBURG OR
97471-1516
US

V. Phone/Fax

Practice location:
  • Phone: 541-677-4463
  • Fax: 541-677-3379
Mailing address:
  • Phone: 541-677-6111
  • Fax: 541-677-6140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number201505556NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPN 0000005657
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN0000055333
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: