Provider Demographics
NPI:1144250267
Name:THOMPSON, PENNY L (NP)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:L
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13008
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48901-3008
Mailing Address - Country:US
Mailing Address - Phone:517-253-6320
Mailing Address - Fax:517-253-6321
Practice Address - Street 1:9751 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-9774
Practice Address - Country:US
Practice Address - Phone:517-647-6722
Practice Address - Fax:517-647-6838
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704141434363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4579202Medicaid
MI4579202Medicaid