1174691000 NPI number — MRS. CHRISTINE DENISE PETTERSON OTR

Table of content: MRS. CHRISTINE DENISE PETTERSON OTR (NPI 1174691000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174691000 NPI number — MRS. CHRISTINE DENISE PETTERSON OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETTERSON
Provider First Name:
CHRISTINE
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KENNEDY
Provider Other First Name:
CHRISTINE
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1174691000
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
60 ABIGAIL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLCHESTER
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05446-3875
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-655-4240
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4066 SHELBURNE RD
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
SHELBURNE
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05482-6905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-985-8211
Provider Business Practice Location Address Fax Number:
802-985-8733
Provider Enumeration Date:
11/30/2006

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: 225X00000X , with the licence number:  072-0000464 , 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)





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