Provider Demographics
NPI:1548636327
Name:THIBEAULT, ALLECIA (FNP)
Entity type:Individual
Prefix:
First Name:ALLECIA
Middle Name:
Last Name:THIBEAULT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31235
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-1235
Mailing Address - Country:US
Mailing Address - Phone:172-752-0324
Mailing Address - Fax:520-324-1700
Practice Address - Street 1:2208 W WILLOW KNOLLS DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1467
Practice Address - Country:US
Practice Address - Phone:309-693-9600
Practice Address - Fax:309-693-3616
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013081363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner