Provider Demographics
NPI:1598771313
Name:THIBEAULT, SUSAN M (CRNA, APRN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:THIBEAULT
Suffix:
Gender:F
Credentials:CRNA, APRN
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:VERRENGIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, CRNA
Mailing Address - Street 1:3998 FAIR RIDGE DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:326 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:18764
Practice Address - Country:US
Practice Address - Phone:860-889-8331
Practice Address - Fax:703-766-9725
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003212367500000X
CT3212367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004250403Medicaid
CT430001134Medicare PIN