Healthcare Provider Details

I. General information

NPI: 1245208248
Provider Name (Legal Business Name): AMANDA H THIBERT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BROOKLINE AVE
BOSTON MA
02215-3904
US

IV. Provider business mailing address

133 BROOKLINE AVE FL 9
BOSTON MA
02215-3904
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-1000
  • Fax: 617-421-6084
Mailing address:
  • Phone: 617-421-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number177950
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number177950
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: