Provider Demographics
NPI:1912463480
Name:THIBODEAU, AMANDA (RN, PHN)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1583 ARCADE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-1051
Mailing Address - Country:US
Mailing Address - Phone:651-266-1241
Mailing Address - Fax:651-266-1201
Practice Address - Street 1:555 CEDAR ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2209
Practice Address - Country:US
Practice Address - Phone:651-266-1241
Practice Address - Fax:651-266-1201
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2130295163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse