| Doctor Name: | AMY THERIAULT |
| NPI Number: | 1295107977 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | CRNP |
| License Number: | R165542 |
| Business Practice Address: | 103 Cool Springs Rd North East, MD - 219012902 |
| Business Phone Number: | 4103222265 |
| Business Fax Number: | |
| Mailing Address: | 500 Upper Chesapeake Dr, BEL AIR |
| State: | MD |
| Postal Code: | 210144324 |
| Phone Number: | 4436431000 |
| Fax Number: | |
| NPI Enumeration Date: | 10/21/2015 |
| NPI Last Update Date: | 10/21/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | R165542 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MD |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |