Healthcare Provider Details

I. General information

NPI: 1558817163
Provider Name (Legal Business Name): SHERRI LYNN THEBERGE RN, IBCLC, LMT, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 05/11/2022
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 HOXSIE AVE
WARWICK RI
02889-1444
US

IV. Provider business mailing address

60 HOXSIE AVE
WARWICK RI
02889-1444
US

V. Phone/Fax

Practice location:
  • Phone: 340-514-3299
  • Fax:
Mailing address:
  • Phone: 340-514-3299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number11157
License Number StateVI
# 2
Primary TaxonomyN
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number11157
License Number StateVI
# 3
Primary TaxonomyN
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number11157
License Number StateVI
# 4
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number8125-26
License Number StateVI
# 5
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number11157
License Number StateVI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: