Healthcare Provider Details

I. General information

NPI: 1750415063
Provider Name (Legal Business Name): NICOLE R HYNES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 09/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE RHEUMATOLOGY ACC 5TH FLOOR
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

393 TWIN PEAKS RD
WATERBURY CENTER VT
05677-7059
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-4574
  • Fax:
Mailing address:
  • Phone: 802-244-8405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0600002821
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number0420011649
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: