Provider Demographics
NPI:1891479424
Name:THIBAULT, ALEXA TAYLOR
Entity Type:Individual
Prefix:
First Name:ALEXA
Middle Name:TAYLOR
Last Name:THIBAULT
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 1:3652 CEDAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-3524
Mailing Address - Country:US
Mailing Address - Phone:906-430-8163
Mailing Address - Fax:
Practice Address - Street 1:3652 CEDAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-3524
Practice Address - Country:US
Practice Address - Phone:906-430-8163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula