MEDICARE: KRISTINA MYRTIS UNIKEWICZ

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	390200000X	Student in an Organized Health Care Education/Training Program
2	363LF0000X	Family Nurse Practitioner	101.0134485	VT

General Provider Information

NPI Number	:	1598315236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA MYRTIS UNIKEWICZ

Provider Business Mailing Address
First Line	:	12 CHURCH ST
Second Line	:
City	:	SWANTON
State	:	VT
Zip	:	05488-1447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 CHURCH ST
Second Line	:
City	:	SWANTON
State	:	VT
Zip	:	05488-1447
Country	:	US
Telephone Number	:	802-868-3175
Fax Number	:

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

Provider Enumeration Date	:	09/15/2019
Last Update Date	:	06/17/2024

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