Healthcare Provider Details

I. General information

NPI: 1316886112
Provider Name (Legal Business Name): WYATT KILBURN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 CENTRE DR
MILTON VT
05468-3104
US

IV. Provider business mailing address

2 GARDEN GATE CIR
NORTH YARMOUTH ME
04097-6574
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-4322
  • Fax: 802-847-1570
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: