Healthcare Provider Details

I. General information

NPI: 1821564527
Provider Name (Legal Business Name): NICHOLAS WECKSTEIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 10/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 LOMBARD LN
SOUTH HERO VT
05486-4302
US

IV. Provider business mailing address

61 CASE PKWY
BURLINGTON VT
05401-1506
US

V. Phone/Fax

Practice location:
  • Phone: 603-717-8127
  • Fax:
Mailing address:
  • Phone: 603-717-8127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number026.0137014
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: