Healthcare Provider Details

I. General information

NPI: 1891288486
Provider Name (Legal Business Name): SAMANTHA O'SULLIVAN COONEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 WATER TOWER RD # 1
ENOSBURG FALLS VT
05450-6097
US

IV. Provider business mailing address

600 BLAIR PARK RD STE 285
WILLISTON VT
05495-7586
US

V. Phone/Fax

Practice location:
  • Phone: 802-933-6664
  • Fax: 802-933-8333
Mailing address:
  • Phone: 802-288-1140
  • Fax: 802-288-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number101.0134162
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: