Provider Demographics
NPI:1477955433
Name:THIBAULT, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:THIBAULT
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 1:8933 ACTIVITY RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4427
Mailing Address - Country:US
Mailing Address - Phone:858-653-6085
Mailing Address - Fax:
Practice Address - Street 1:8933 ACTIVITY RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4427
Practice Address - Country:US
Practice Address - Phone:858-653-6085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-22
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14671172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker