Healthcare Provider Details

I. General information

NPI: 1235411174
Provider Name (Legal Business Name): MARCIA M BRISTOW MS RD CD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2011
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 LAKESIDE AVE
BURLINGTON VT
05401-4939
US

IV. Provider business mailing address

3528 HARBOR RD
SHELBURNE VT
05482-7795
US

V. Phone/Fax

Practice location:
  • Phone: 802-777-9691
  • Fax: 802-985-9947
Mailing address:
  • Phone: 802-777-9691
  • Fax: 802-985-9947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number0740076077
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: