Basic Information
| Provider Information | |||||||||
| NPI: | 1144250267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172536320 | ||||||||
| FaxNumber: | 5172536321 | ||||||||
| Practice Location | |||||||||
| Address1: | 9751 E GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488759774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176476722 | ||||||||
| FaxNumber: | 5176476838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 04/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704141434 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 4579202 | 05 | MI | MEDICAID |