Provider Demographics
NPI:1265767792
Name:THIBODEAUX, MOLLY ROE (CFNP)
Entity type:Individual
Prefix:MRS
First Name:MOLLY
Middle Name:ROE
Last Name:THIBODEAUX
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-3744
Mailing Address - Country:US
Mailing Address - Phone:970-749-5901
Mailing Address - Fax:
Practice Address - Street 1:1 MERCADO ST
Practice Address - Street 2:SUITE 145 MERCY MEDICAL PLAZA
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7306
Practice Address - Country:US
Practice Address - Phone:970-247-5543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-16
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CONP 10151363LF0000X
CO192552363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily