Provider Demographics
NPI:1548714082
Name:THEVENAU, GRETCHEN MARIE (AP)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:MARIE
Last Name:THEVENAU
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 167TH PL
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:FL
Mailing Address - Zip Code:32060-8025
Mailing Address - Country:US
Mailing Address - Phone:281-658-5459
Mailing Address - Fax:
Practice Address - Street 1:116 CONNER ST NE
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:FL
Practice Address - Zip Code:32064-2470
Practice Address - Country:US
Practice Address - Phone:386-361-8462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-13
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0001948171100000X
FLAP3345171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist