Provider Demographics
NPI:1669766721
Name:THIBAUT, COLLEEN LYN (DO)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:LYN
Last Name:THIBAUT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1225 E GARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5115
Mailing Address - Country:US
Mailing Address - Phone:704-865-7416
Mailing Address - Fax:704-865-7232
Practice Address - Street 1:1225 E GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5115
Practice Address - Country:US
Practice Address - Phone:704-865-7416
Practice Address - Fax:704-865-7232
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101019426207V00000X
NC2015-01221207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology