Provider Demographics
NPI:1679964019
Name:THIBAULT, GINGER NICHOLE
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:NICHOLE
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GINGER
Other - Middle Name:NICHOLE
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1985 GARRY OAKS AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:DUPONT
Mailing Address - State:WA
Mailing Address - Zip Code:98327-6703
Mailing Address - Country:US
Mailing Address - Phone:405-905-0212
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-4426
Practice Address - Country:US
Practice Address - Phone:253-968-2464
Practice Address - Fax:253-968-0384
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0077265163WP0200X, 363LP0200X
WAAP61333001363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics