Healthcare Provider Details

I. General information

NPI: 1740307156
Provider Name (Legal Business Name): DEBRA THERIAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/19/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 HODSKIN ST
CANTON NY
13617-1175
US

IV. Provider business mailing address

494 COUNTY ROUTE 24
GOUVERNEUR NY
13642-3555
US

V. Phone/Fax

Practice location:
  • Phone: 315-379-1445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number315087
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: