Healthcare Provider Details

I. General information

NPI: 1033196639
Provider Name (Legal Business Name): MARY GILL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY CORCORAN NP

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 PORTER DRIVE
MIDDLEBURY VT
05753
US

IV. Provider business mailing address

104 PORTER DR
MIDDLEBURY VT
05753-8527
US

V. Phone/Fax

Practice location:
  • Phone: 802-388-7959
  • Fax: 802-388-8136
Mailing address:
  • Phone: 802-388-8808
  • Fax: 802-388-8322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1010018668
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: