Healthcare Provider Details

I. General information

NPI: 1043520448
Provider Name (Legal Business Name): JENNIFER G. HUMPHRIES LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2010
Last Update Date: 10/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 SOUTH BAYLEY HAZEN RD. HOME ACRES FARM
RYEGATE VT
05042
US

IV. Provider business mailing address

PO BOX 202
PLAINFIELD VT
05667-0202
US

V. Phone/Fax

Practice location:
  • Phone: 802-584-4679
  • Fax:
Mailing address:
  • Phone: 802-454-1915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number025.0069058
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: