Provider Demographics
NPI:1861706335
Name:NUTTY, KIRSTEN ANN THIBODEAU (LNP)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:ANN THIBODEAU
Last Name:NUTTY
Suffix:
Gender:F
Credentials:LNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1009
Mailing Address - Country:US
Mailing Address - Phone:716-323-0225
Mailing Address - Fax:716-323-0293
Practice Address - Street 1:1001 MAIN ST FL 4
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1009
Practice Address - Country:US
Practice Address - Phone:716-323-0110
Practice Address - Fax:716-323-0296
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382142363LP0222X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03351782Medicaid
NYJ400047640Medicare PIN