Basic Information
| Provider Information | |||||||||
| NPI: | 1669766721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THIBAUT | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 E GARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280545115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048657416 | ||||||||
| FaxNumber: | 7048657232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 E GARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280545115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048657416 | ||||||||
| FaxNumber: | 7048657232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2011 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 5101019426 | MI | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 2015-01221 | NC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.