Healthcare Provider Details

I. General information

NPI: 1215364062
Provider Name (Legal Business Name): KARYN HARVEY FAREVAAG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2013
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 BLAIR PARK RD
WILLISTON VT
05495-7530
US

IV. Provider business mailing address

P.O. BOX 30
GREAT BARRINGTON MA
01230
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-1470
  • Fax:
Mailing address:
  • Phone: 413-528-9311
  • Fax: 413-644-0274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number101-0134554
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number265605
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number101-0134554
License Number StateVT
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN265605
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: