Basic Information
| Provider Information | |||||||||
| NPI: | 1972245421 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIBAULT | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 47 HIGH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | NORTH ANDOVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018452637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782584734 | ||||||||
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| Practice Location | |||||||||
| Address1: | 295 VARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789376439 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2022 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN2299317 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.