Provider Demographics
NPI:1659391092
Name:THIBAULT, LENITA (MD)
Entity Type:Individual
Prefix:DR
First Name:LENITA
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:135 W RAVINE RD
Practice Address - Street 2:SUITE 1A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3847
Practice Address - Country:US
Practice Address - Phone:423-224-4920
Practice Address - Fax:423-224-4929
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21333207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010169836Medicaid
TN103I162884Medicare PIN
TNP00267377Medicare PIN
TNE81567Medicare UPIN
TN3058737Medicare PIN