Healthcare Provider Details

I. General information

NPI: 1124943832
Provider Name (Legal Business Name): MAGGIE JANE DERVIS RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

346 GOODRICH FOUR CORNERS RD
NORWICH VT
05055-9797
US

IV. Provider business mailing address

346 GOODRICH FOUR CORNERS RD
NORWICH VT
05055-9797
US

V. Phone/Fax

Practice location:
  • Phone: 815-200-7287
  • Fax:
Mailing address:
  • Phone: 815-200-7287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2502
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: