Basic Information
| Provider Information | |||||||||
| NPI: | 1245208248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIBERT | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 BROOKLINE AVE FL 9 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022153904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174218888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 133 BROOKLINE AVE | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022153904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174211000 | ||||||||
| FaxNumber: | 6174216084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 177950 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363L00000X | 177950 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0357685 | 05 | MA | MEDICAID | NP9991 | 01 | MA | BLUE CROSS | OTHER | 39176 | 01 | MA | HARVARD PILGRIM | OTHER |