Healthcare Provider Details

I. General information

NPI: 1639891013
Provider Name (Legal Business Name): BIANCA SHANE' THOMPSON MSN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2022
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200A TECHNOLOGY CT
CHANTILLY VA
20151-1214
US

IV. Provider business mailing address

15200 LEICESTERSHIRE ST UNIT 441
WOODBRIDGE VA
22191-5945
US

V. Phone/Fax

Practice location:
  • Phone: 540-709-1737
  • Fax:
Mailing address:
  • Phone: 571-247-7158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM07386
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: