Healthcare Provider Details

I. General information

NPI: 1245721281
Provider Name (Legal Business Name): MICHELLE MAE MORTIMER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE MAE EARLEY PN, RN

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 DUKE ROAD
WILLIAMSVILLE VT
05362
US

IV. Provider business mailing address

PO BOX 130
WILLIAMSVILLE VT
05362-0130
US

V. Phone/Fax

Practice location:
  • Phone: 802-579-5138
  • Fax:
Mailing address:
  • Phone: 802-579-5138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number026.0025732
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: