Provider Demographics
NPI:1174970354
Name:THIBODEAU, SHELLY A (RN)
Entity type:Individual
Prefix:
First Name:SHELLY
Middle Name:A
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:ME
Mailing Address - Zip Code:04949-3354
Mailing Address - Country:US
Mailing Address - Phone:207-314-0736
Mailing Address - Fax:
Practice Address - Street 1:6 AVIS DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:ME
Practice Address - Zip Code:04927-3728
Practice Address - Country:US
Practice Address - Phone:207-426-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-18
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN66548163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse