Provider Demographics
NPI:1073129516
Name:THIBAULT, COLBY (RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:COLBY
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 CAPTAIN JOHN JACOBS RD APT 209
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-5372
Mailing Address - Country:US
Mailing Address - Phone:774-319-1606
Mailing Address - Fax:
Practice Address - Street 1:36 CAPTAIN JOHN JACOBS RD APT 209
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-5372
Practice Address - Country:US
Practice Address - Phone:774-319-1606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN01053133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty