Healthcare Provider Details

I. General information

NPI: 1154509404
Provider Name (Legal Business Name): KAITLIN E BRENNY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 01/15/2024
Certification Date: 01/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4178 HIGHBRIDGE RD
FAIRFAX VT
05454-5446
US

IV. Provider business mailing address

44 MAIN ST STE 200
RICHFORD VT
05476-1141
US

V. Phone/Fax

Practice location:
  • Phone: 802-582-2600
  • Fax:
Mailing address:
  • Phone: 802-255-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055-0030917
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: