Provider Demographics
NPI:1912471665
Name:TIBODEAU, ABBY JO (RD, LD)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:JO
Last Name:TIBODEAU
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MALLARD CT
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-1860
Mailing Address - Country:US
Mailing Address - Phone:507-327-7993
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5066
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3033133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered