Provider Demographics
NPI:1699809822
Name:THIBAULT, LORI (CRNA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04276-2104
Mailing Address - Country:US
Mailing Address - Phone:207-369-1000
Mailing Address - Fax:
Practice Address - Street 1:420 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:RUMFORD
Practice Address - State:ME
Practice Address - Zip Code:04276-2104
Practice Address - Country:US
Practice Address - Phone:207-369-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERO26818367500000X
MEAA083098367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEJX2231Medicare PIN
MEJX2232Medicare UPIN