Provider Demographics
NPI:1396305082
Name:THIBAULT, JUDY ANNE
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:ANNE
Last Name:THIBAULT
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 1:203 MUNSEL CREEK LOOP
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97439-9235
Mailing Address - Country:US
Mailing Address - Phone:541-999-7109
Mailing Address - Fax:
Practice Address - Street 1:203 MUNSEL CREEK LOOP
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-9235
Practice Address - Country:US
Practice Address - Phone:541-999-7109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-16
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200440287RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health