Provider Demographics
NPI:1669749438
Name:THIBODEAUX, NICOLE MAE (RN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MAE
Last Name:THIBODEAUX
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 S OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-8347
Mailing Address - Country:US
Mailing Address - Phone:920-410-9352
Mailing Address - Fax:
Practice Address - Street 1:1640 S OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-8347
Practice Address - Country:US
Practice Address - Phone:920-410-9352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-22
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI174033-30163W00000X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse