Healthcare Provider Details

I. General information

NPI: 1114043064
Provider Name (Legal Business Name): SANDRA DENISE THEBAUD-YOUNG APRN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 EASTON AVENUE NEW BRUNSWICK
NEW BRUNSWICK NJ
08901
US

IV. Provider business mailing address

239 40TH ST IRVINGTON
IRVINGTON NJ
07111-1100
US

V. Phone/Fax

Practice location:
  • Phone: 908-392-1948
  • Fax: 973-337-2045
Mailing address:
  • Phone: 973-371-5563
  • Fax: 973-337-2045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00129300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: