Healthcare Provider Details

I. General information

NPI: 1255121984
Provider Name (Legal Business Name): KELLY MANDIGO HAVEN RN, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

164 WOODBURY RD
BURLINGTON VT
05408-5716
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-6200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number026.0104043
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: