Healthcare Provider Details

I. General information

NPI: 1598771313
Provider Name (Legal Business Name): SUSAN M THIBEAULT CRNA, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN M VERRENGIA APRN, CRNA

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 WASHINGTON STREET
NORWICH CT
18764
US

IV. Provider business mailing address

3998 FAIR RIDGE DRIVE SUITE 300
FAIRFAX VA
22033
US

V. Phone/Fax

Practice location:
  • Phone: 860-889-8331
  • Fax: 703-766-9725
Mailing address:
  • Phone: 703-295-9360
  • Fax: 703-766-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number003212
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3212
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: