Provider Demographics
NPI:1255864906
Name:THIBERT, KELLY (DO, MPH)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:THIBERT
Suffix:
Gender:F
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7124 FOSSIL LAKE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-4001
Mailing Address - Country:US
Mailing Address - Phone:954-258-3303
Mailing Address - Fax:
Practice Address - Street 1:6900 N PECOS RD
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-4400
Practice Address - Country:US
Practice Address - Phone:702-791-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-10
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17069207Q00000X
NVDO3569207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine