MEDICARE: MARKITA MARIE THOMPSON DNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	4704218652	MI
2	363LG0600X	Gerontology Nurse Practitioner	4704218652	MI
3	363LP2300X	Primary Care Nurse Practitioner	4704218652	MI
4	363LA2200X	Adult Health Nurse Practitioner	4704218652	MI

General Provider Information

NPI Number	:	1730556291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARKITA MARIE THOMPSON DNP

Provider Business Mailing Address
First Line	:	1759 WABASH ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48216-1843
Country	:	US
Telephone Number	:	313-613-9392
Fax Number	:

Provider Business Practice Location Address
First Line	:	277 GRATIOT AVE STE 100A8919
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48226-2239
Country	:	US
Telephone Number	:	313-515-5145
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2015
Last Update Date	:	03/17/2018

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