Healthcare Provider Details

I. General information

NPI: 1003633538
Provider Name (Legal Business Name): EMILY CATHERINE THIBEAULT RN-BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 BOLDUC AVE
FORT KENT ME
04743-1602
US

IV. Provider business mailing address

PO BOX 309
EAGLE LAKE ME
04739-0309
US

V. Phone/Fax

Practice location:
  • Phone: 207-834-3971
  • Fax: 207-834-3837
Mailing address:
  • Phone: 207-444-5973
  • Fax: 207-444-5520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN85302
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: