Healthcare Provider Details

I. General information

NPI: 1962906909
Provider Name (Legal Business Name): KERRY E DETWEILER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5024 MAIN RD
HUNTINGTON VT
05462-9724
US

IV. Provider business mailing address

5024 MAIN RD
HUNTINGTON VT
05462-9724
US

V. Phone/Fax

Practice location:
  • Phone: 518-488-8132
  • Fax:
Mailing address:
  • Phone: 518-488-8132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number104.0116901
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number074.0131360
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: