Basic Information
| Provider Information | |||||||||
| NPI: | 1669809653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIBAULT | ||||||||
| FirstName: | JEANETTE | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN, CNP, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GOURD | ||||||||
| OtherFirstName: | JEANETTE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 BALD HILL ROAD | ||||||||
| Address2: | SUITE 511 | ||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017388100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 BALD HILL ROAD | ||||||||
| Address2: | SUITE 511 | ||||||||
| City: | WARWICK | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017388100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2013 | ||||||||
| LastUpdateDate: | 12/01/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APRN00134 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.