Provider Demographics
NPI:1114043064
Name:THEBAUD-YOUNG, SANDRA DENISE (APRN-BC)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:DENISE
Last Name:THEBAUD-YOUNG
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:239 40TH ST
Mailing Address - Street 2:IRVINGTON
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-1100
Mailing Address - Country:US
Mailing Address - Phone:973-371-5563
Mailing Address - Fax:973-337-2045
Practice Address - Street 1:254 EASTON AVENUE
Practice Address - Street 2:NEW BRUNSWICK
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901
Practice Address - Country:US
Practice Address - Phone:908-392-1948
Practice Address - Fax:973-337-2045
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00129300363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0147320Medicaid
112818VGDOtherMEDICARE