Healthcare Provider Details

I. General information

NPI: 1710841085
Provider Name (Legal Business Name): KELLI A WALSH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PINE ST
RUTLAND VT
05701-2842
US

IV. Provider business mailing address

30 PINE ST
RUTLAND VT
05701-2842
US

V. Phone/Fax

Practice location:
  • Phone: 802-775-2381
  • Fax: 802-775-4020
Mailing address:
  • Phone: 802-775-2381
  • Fax: 802-775-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: