Provider Demographics
NPI:1902388291
Name:THIBODEAUX, KELLY CATES
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CATES
Last Name:THIBODEAUX
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 1:20503 NEWFALLS CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-7856
Mailing Address - Country:US
Mailing Address - Phone:713-213-7370
Mailing Address - Fax:
Practice Address - Street 1:20503 NEWFALLS CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-7856
Practice Address - Country:US
Practice Address - Phone:713-213-7370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX161705164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX161705Medicaid