Healthcare Provider Details

I. General information

NPI: 1740636612
Provider Name (Legal Business Name): DONNA M THIBAULT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 N HIGHLAND AVE
AURORA IL
60506-1401
US

IV. Provider business mailing address

523 S RIVER ST
MONTGOMERY IL
60538-1519
US

V. Phone/Fax

Practice location:
  • Phone: 630-966-4319
  • Fax: 630-859-3841
Mailing address:
  • Phone: 630-966-4319
  • Fax: 630-859-3841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041197590
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: