1366756686 NPI number — PAULETTE J THABAULT ANP

Table of content: PAULETTE J THABAULT ANP (NPI 1366756686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366756686 NPI number — PAULETTE J THABAULT ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THABAULT
Provider First Name:
PAULETTE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANP
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:
1366756686
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
617 RIVERSIDE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05401-1601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-864-6309
Provider Business Mailing Address Fax Number:
802-860-4313

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
368 DORSET ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
SOUTH BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05403-6236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-860-1441
Provider Business Practice Location Address Fax Number:
802-860-4646
Provider Enumeration Date:
07/28/2010

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:  1010010736 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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