Healthcare Provider Details

I. General information

NPI: 1891601803
Provider Name (Legal Business Name): KINDALYN THIBEAUX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2036 CHARTER LN
LITHONIA GA
30058-8969
US

IV. Provider business mailing address

2036 CHARTER LN
LITHONIA GA
30058-8969
US

V. Phone/Fax

Practice location:
  • Phone: 404-578-8881
  • Fax:
Mailing address:
  • Phone: 404-578-8881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberF7T8N3M6
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: