Healthcare Provider Details

I. General information

NPI: 1376437673
Provider Name (Legal Business Name): KAITLYN THEBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 BOGUE ST
EAST LANSING MI
48824-6207
US

IV. Provider business mailing address

1666 WINTERCREST ST
EAST LANSING MI
48823-1761
US

V. Phone/Fax

Practice location:
  • Phone: 517-432-8163
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704364447
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: