Provider Demographics
NPI:1104477942
Name:THIBAULT, ALLISON EVELYN (RDN)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:EVELYN
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1095 MORRIS AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-7143
Mailing Address - Country:US
Mailing Address - Phone:201-951-7607
Mailing Address - Fax:
Practice Address - Street 1:1095 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-7143
Practice Address - Country:US
Practice Address - Phone:201-951-7607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-23
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered