MEDICARE: MRS. ALICE CECILE PEZZULICH FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	0027640	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00059357	OTHER	VT	VERMONT BLUE CROSS
3	GONP4075	OTHER		CHAMPUS/TRICARE
4	414900	OTHER		CIGNA
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	696890	OTHER		MVP HEALTHPLAN
7	GONP4075	OTHER		PALMETTO GBA

General Provider Information

NPI Number	:	1053307918
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALICE CECILE PEZZULICH FNP

Provider Business Mailing Address
First Line	:	9 CHURCH STREET
Second Line	:	PO BOX 690
City	:	ARLINGTON
State	:	VT
Zip	:	05250-0690
Country	:	US
Telephone Number	:	802-375-6566
Fax Number	:	802-375-6828

Provider Business Practice Location Address
First Line	:	9 CHURCH ST.
Second Line	:
City	:	ARLINGTON
State	:	VT
Zip	:	05250
Country	:	US
Telephone Number	:	802-375-6566
Fax Number	:	802-375-6828

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	06/23/2015

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