Healthcare Provider Details

I. General information

NPI: 1043592751
Provider Name (Legal Business Name): KIMBERLY ANN HOLBROOK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2011
Last Update Date: 03/07/2023
Certification Date: 12/21/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE 354MP2
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVE 354MP2
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-3496
  • Fax: 802-847-0574
Mailing address:
  • Phone: 802-847-3496
  • Fax: 802-847-0574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055-0031112
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: