Healthcare Provider Details

I. General information

NPI: 1548774318
Provider Name (Legal Business Name): SHELLEY K THIEBEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 11/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 VINE ST
CINCINNATI OH
45220-2213
US

IV. Provider business mailing address

1833 CURRY BRANCH DR
TIPP CITY OH
45371-2482
US

V. Phone/Fax

Practice location:
  • Phone: 513-861-3100
  • Fax:
Mailing address:
  • Phone: 937-418-3390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN259594
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: