Provider Demographics
NPI:1316382120
Name:THIBODEAU, LISA ELLEN (CNM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ELLEN
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:CNM
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:85 HERRICK ST
Mailing Address - Street 2:NORTH SHORE BIRTH CENTER
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1790
Mailing Address - Country:US
Mailing Address - Phone:978-927-7880
Mailing Address - Fax:978-524-6082
Practice Address - Street 1:85 HERRICK ST
Practice Address - Street 2:NORTH SHORE BIRTH CENTER
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1790
Practice Address - Country:US
Practice Address - Phone:978-927-7880
Practice Address - Fax:978-524-6082
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2018-02-05
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Provider Licenses
StateLicense IDTaxonomies
MARN239148367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife