MEDICARE: MARIE THEBAUD LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	318729-1	NY

General Provider Information

NPI Number	:	1982006870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE THEBAUD LPN

Provider Business Mailing Address
First Line	:	140 W. ECKERSON RD. APT 1A
Second Line	:
City	:	SPRING VALLEY
State	:	NY
Zip	:	10977
Country	:	US
Telephone Number	:	845-553-4089
Fax Number	:

Provider Business Practice Location Address
First Line	:	140 W ECKERSON RD APT 1A
Second Line	:
City	:	SPRING VALLEY
State	:	NY
Zip	:	10977-3517
Country	:	US
Telephone Number	:	845-553-4089
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2014
Last Update Date	:	09/23/2014

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