Provider Demographics
NPI:1710418322
Name:TIBAUD, JULIE
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:TIBAUD
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 1:3700 CURRY FORD RD
Mailing Address - Street 2:B8
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2677
Mailing Address - Country:US
Mailing Address - Phone:407-779-6708
Mailing Address - Fax:
Practice Address - Street 1:3700 CURRY FORD RD
Practice Address - Street 2:B8
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2677
Practice Address - Country:US
Practice Address - Phone:407-779-6708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376J00000X, 261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020485500Medicaid