Healthcare Provider Details

I. General information

NPI: 1700479656
Provider Name (Legal Business Name): WINTA QUEENIE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 03/04/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 RECREATION BLDG UNIVERSITY PARK, PA, 16802
STATE COLLEGE PA
16802
US

IV. Provider business mailing address

131 HEISTER ST 305
STATE COLLEGE PA
16801
US

V. Phone/Fax

Practice location:
  • Phone: 914-258-7505
  • Fax:
Mailing address:
  • Phone: 914-258-7505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: