Provider Demographics
NPI:1164661088
Name:THIBODEAU, NICOLE LYNN
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
Last Name:THIBODEAU
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 1:47295 NAPOLI LN
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-2672
Mailing Address - Country:US
Mailing Address - Phone:586-268-0163
Mailing Address - Fax:
Practice Address - Street 1:47295 NAPOLI LN
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-2672
Practice Address - Country:US
Practice Address - Phone:586-268-0163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant