1003073644 NPI number — MS. MARILYN JEAN RENAUDETTE M.A.

Table of content: MS. MARILYN JEAN RENAUDETTE M.A. (NPI 1003073644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003073644 NPI number — MS. MARILYN JEAN RENAUDETTE M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RENAUDETTE
Provider First Name:
MARILYN
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDWARDS
Provider Other First Name:
MARILYN
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003073644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 IAN PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495-4408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-764-1282
Provider Business Mailing Address Fax Number:
802-764-1282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4185 ST GEORGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLISTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05495-7695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-651-7730
Provider Business Practice Location Address Fax Number:
802-651-7730
Provider Enumeration Date:
05/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  047-0000736 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1015179 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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