MEDICARE: ALISSA NICHOLE THOMPSON BSN-RN, PMHNP STUDE

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	163WP0808X	Psychiatric/Mental Health Registered Nurse	041434677	IL
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209026304	IL

General Provider Information

NPI Number	:	1770101420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISSA NICHOLE THOMPSON BSN-RN, PMHNP STUDE

Provider Business Mailing Address
First Line	:	2040 W HADDON AVE APT 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-3623
Country	:	US
Telephone Number	:	312-966-5585
Fax Number	:

Provider Business Practice Location Address
First Line	:	3976 N AVONDALE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2900
Country	:	US
Telephone Number	:	312-966-5585
Fax Number	:

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

Provider Enumeration Date	:	07/09/2020
Last Update Date	:	02/21/2023

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