Healthcare Provider Details

I. General information

NPI: 1306967054
Provider Name (Legal Business Name): ILENE B SIEGEL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 10/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 FISHER RD
BERLIN VT
05602-9516
US

IV. Provider business mailing address

PO BOX 547 ATT: CVMC FINANCE DEPT
BARRE VT
05641-0547
US

V. Phone/Fax

Practice location:
  • Phone: 802-371-4152
  • Fax: 802-371-4572
Mailing address:
  • Phone: 802-371-4152
  • Fax: 802-371-4572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number074-0000033
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: