Provider Demographics
NPI:1871048629
Name:THOMPSON, EILEEN
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13691 METRO PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3033 WINKLER AVE SUITE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-4327
Practice Address - Country:US
Practice Address - Phone:239-277-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 363A00000X, 363AM0700X
FLPA9114023363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant