Individual
KELLY THIBAULT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CRNP
Contact information
Practice address
201 LYONS AVE, NEWARK, NJ 07112-2027
(973) 926-7000
Mailing address
60 OAK PL, FAIR HAVEN, NJ 07704-3510
(732) 768-7857
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
Primary
26NJ0048730
NJ
363LP0200X
Pediatric Nurse Practitioner
382415
NY
Other
Enumeration date
07/28/2014
Last updated
08/26/2025
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