Provider Demographics
NPI:1548808793
Name:THOMPSON, AMANDA RAE (L AC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:RAE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2346 31ST DR # 1F
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4137
Mailing Address - Country:US
Mailing Address - Phone:727-418-4696
Mailing Address - Fax:
Practice Address - Street 1:139 FULTON ST RM 208
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2538
Practice Address - Country:US
Practice Address - Phone:212-513-0437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6584171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist