Healthcare Provider Details

I. General information

NPI: 1194379669
Provider Name (Legal Business Name): NICOLE MARIE CLOUTIER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401
US

IV. Provider business mailing address

393 CHURCH RD
COLCHESTER VT
05401
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-2370
  • Fax:
Mailing address:
  • Phone: 413-433-2271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number026.0089278
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number101.0134384
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: