Healthcare Provider Details

I. General information

NPI: 1508297599
Provider Name (Legal Business Name): CONNIE FISK N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COMMONS ST
RUTLAND VT
05701-4652
US

IV. Provider business mailing address

160 ALLEN ST
RUTLAND VT
05701-4560
US

V. Phone/Fax

Practice location:
  • Phone: 802-747-1857
  • Fax: 802-747-1026
Mailing address:
  • Phone: 802-747-1857
  • Fax: 802-747-0129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF401672
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101.0134648
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: