1114043064 NPI number — MRS. SANDRA DENISE THEBAUD-YOUNG APRN-BC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114043064 NPI number — MRS. SANDRA DENISE THEBAUD-YOUNG APRN-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THEBAUD-YOUNG
Provider First Name:
SANDRA
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114043064
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
239 40TH ST
Provider Second Line Business Mailing Address:
IRVINGTON
Provider Business Mailing Address City Name:
IRVINGTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07111-1100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-371-5563
Provider Business Mailing Address Fax Number:
973-337-2045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
254 EASTON AVENUE
Provider Second Line Business Practice Location Address:
NEW BRUNSWICK
Provider Business Practice Location Address City Name:
NEW BRUNSWICK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-392-1948
Provider Business Practice Location Address Fax Number:
973-337-2045
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  26NJ00129300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0147320 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 112818VGD . This is a "MEDICARE" identifier . This identifiers is of the category "OTHER".




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