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General NPI Number Information
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NPI Number | 1396275582
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Entity Type | Individual
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Provider Name | ASHLEY MARIE THIBODEAU
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Gender | Female
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Dates
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Enumeration Date | 06/19/2017
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 3950 BEAUBIEN ST
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City | DETROIT
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State | MI
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Zip | 48201-2166
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Country | US
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Telephone | 313-832-9620
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Fax |
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Provider Business Mailing Address
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Address Line | 26901 BEAUMONT BLVD STE 3D
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City | SOUTHFIELD
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State | MI
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Zip | 48033-3849
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 4704293510
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 163WP0200X
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Taxonomy Name | Pediatric Registered Nurse
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License Number | 4704293510
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 4704293510
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | AP60810818
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License Number State | WA
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