Healthcare Provider Details

I. General information

NPI: 1487418877
Provider Name (Legal Business Name): NICOLE R SUGRUE BA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE R BROTHERS BA

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 10/27/2025
Certification Date: 10/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 HOSPITAL LOOP
BERLIN VT
05602-9105
US

IV. Provider business mailing address

PO BOX 647
MONTPELIER VT
05601-0647
US

V. Phone/Fax

Practice location:
  • Phone: 802-479-4083
  • Fax: 802-476-1476
Mailing address:
  • Phone: 802-301-3200
  • Fax: 802-223-0842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number097.0136468
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: