Healthcare Provider Details

I. General information

NPI: 1801208418
Provider Name (Legal Business Name): KIM NICOLE DACEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM NICOLE TANTLINGER FNP-C

II. Dates (important events)

Enumeration Date: 05/30/2014
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 ROOSEVELT HWY STE 132
COLCHESTER VT
05446-4460
US

IV. Provider business mailing address

875 ROOSEVELT HWY STE 132
COLCHESTER VT
05446-4460
US

V. Phone/Fax

Practice location:
  • Phone: 802-864-7483
  • Fax: 802-660-4337
Mailing address:
  • Phone: 802-864-7483
  • Fax: 802-660-4337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0107576
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2284328
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: