Healthcare Provider Details

I. General information

NPI: 1902527641
Provider Name (Legal Business Name): HEATHER SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 09/12/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 PINE HAVEN SHORES RD STE 1111
SHELBURNE VT
05482-7703
US

IV. Provider business mailing address

145 PINE HAVEN SHORES RD STE 1111
SHELBURNE VT
05482-7703
US

V. Phone/Fax

Practice location:
  • Phone: 802-404-2031
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number026.0099991
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: