Provider Demographics
NPI:1740714096
Name:THOMPSON, PHELISHA MICHELLE (LPN)
Entity type:Individual
Prefix:MRS
First Name:PHELISHA
Middle Name:MICHELLE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:PHELISHA
Other - Middle Name:MICHELLE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:2766 W 11 MILE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3033
Mailing Address - Country:US
Mailing Address - Phone:248-542-2424
Mailing Address - Fax:248-542-5621
Practice Address - Street 1:2766 W 11 MILE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-3033
Practice Address - Country:US
Practice Address - Phone:248-542-2424
Practice Address - Fax:248-542-5621
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703078408164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse