Healthcare Provider Details

I. General information

NPI: 1396979423
Provider Name (Legal Business Name): KIMBERLY MADDOCK PRATT REGISTERED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 05/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COLCHESTER AVENUE FLETCHER ALLEN HEALTHCARE
BURLINGTON VT
05401
US

IV. Provider business mailing address

100 COLCHESTER AVENUE FLETCHER ALLEN HEALTHCARE
BURLINGTON VT
05401
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-4760
  • Fax:
Mailing address:
  • Phone: 802-847-4760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number074.0000196
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: