Healthcare Provider Details

I. General information

NPI: 1386196996
Provider Name (Legal Business Name): MRS. MAKENZIE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAKENZIE LONG FNP-BC

II. Dates (important events)

Enumeration Date: 10/30/2016
Last Update Date: 10/18/2020
Certification Date: 10/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 MCINTOSH ST
GHENT WV
25843-1805
US

IV. Provider business mailing address

202 GUYANDOTTE AVE
MULLENS WV
25882-1308
US

V. Phone/Fax

Practice location:
  • Phone: 304-673-0844
  • Fax:
Mailing address:
  • Phone: 304-294-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number92290
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number106985
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: