Healthcare Provider Details

I. General information

NPI: 1174741912
Provider Name (Legal Business Name): LYNNE L COLVILLE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 ROUTE 30 N
BOMOSEEN VT
05732-9647
US

IV. Provider business mailing address

275 ROUTE 30 N
BOMOSEEN VT
05732-9647
US

V. Phone/Fax

Practice location:
  • Phone: 802-468-5641
  • Fax: 802-468-2923
Mailing address:
  • Phone: 802-468-5641
  • Fax: 802-468-2923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101-0011925
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: