Healthcare Provider Details

I. General information

NPI: 1891041968
Provider Name (Legal Business Name): SOPHIE THIBODEAU ECKERT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2012
Last Update Date: 04/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 MEDICAL PKWY SUITE 250
ANNAPOLIS MD
21401-7992
US

IV. Provider business mailing address

2003 MEDICAL PKWY SUITE 250
ANNAPOLIS MD
21401-7992
US

V. Phone/Fax

Practice location:
  • Phone: 410-224-2228
  • Fax:
Mailing address:
  • Phone: 410-224-2228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN2274306
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberR208808
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: