Healthcare Provider Details

I. General information

NPI: 1053540047
Provider Name (Legal Business Name): AMANDA JANE COLEMAN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 07/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 WHIPPLE RD
SOUTH HERO VT
05486-4900
US

IV. Provider business mailing address

27 1/2 LAFOUNTAIN ST
BURLINGTON VT
05401-4236
US

V. Phone/Fax

Practice location:
  • Phone: 802-372-4020
  • Fax:
Mailing address:
  • Phone: 802-999-2023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number025.0054002
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: