Provider Demographics
NPI:1376217075
Name:THIBODEAUX, KATE G (FNPC)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:G
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:POMEROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-404-8200
Mailing Address - Fax:
Practice Address - Street 1:242 BRUNSWICK ST
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:ME
Practice Address - Zip Code:04468-1613
Practice Address - Country:US
Practice Address - Phone:207-827-6128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-05
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP211240363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner