Healthcare Provider Details

I. General information

NPI: 1114257037
Provider Name (Legal Business Name): MS. KATHLEEN SQUIRES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHLEEN SQUIRES R.D.

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 NICHOLS RD
NEWFANE VT
05345-9594
US

IV. Provider business mailing address

50 NICHOLS RD
NEWFANE VT
05345
US

V. Phone/Fax

Practice location:
  • Phone: 802-365-7388
  • Fax:
Mailing address:
  • Phone: 802-365-7388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number074000145
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: