=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669935169
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MISS NICOLE M THOMPSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2019
-----------------------------------------------------
Last Update Date | 03/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 EVES DR STE A100
-----------------------------------------------------
City | MARLTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08053-3126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-267-9400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 JUNIPER CIR
-----------------------------------------------------
City | GLASSBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08028-2950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-812-1689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 25MT00285400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------