1144585530 NPI number — MRS. NICOLE WHITNEY DAVIGNON DPT

Table of content: MRS. NICOLE WHITNEY DAVIGNON DPT (NPI 1144585530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144585530 NPI number — MRS. NICOLE WHITNEY DAVIGNON DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAVIGNON
Provider First Name:
NICOLE
Provider Middle Name:
WHITNEY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144585530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 SAN REMO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BURLINGTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05403-6343
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-865-0010
Provider Business Mailing Address Fax Number:
802-865-0050

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
166 ATHLETIC DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBURNE
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05482-4433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-985-4440
Provider Business Practice Location Address Fax Number:
802-985-4445
Provider Enumeration Date:
07/11/2012

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: 225100000X , with the licence number:  040.0086066 , 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: 0VN3242 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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