=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235463092
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLE RAE SHUTTER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2009
-----------------------------------------------------
Last Update Date | 06/30/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 BELMONT AVE
-----------------------------------------------------
City | BRATTLEBORO
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05301-7110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-258-3905
-----------------------------------------------------
Fax | 802-258-4903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 BLAIR PARK RD STE 285
-----------------------------------------------------
City | WILLISTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05495-7586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-288-1140
-----------------------------------------------------
Fax | 802-288-1144
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD60500534
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 042.0015262
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------