Basic Information
| Provider Information | |||||||||
| NPI: | 1124357215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACAULAY | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | MARIETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.N.P | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PORTER | ||||||||
| OtherFirstName: | LEAH | ||||||||
| OtherMiddleName: | MARIETTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | P.N.P | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 66 KNIGHT LN STE 10 | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054959308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028724343 | ||||||||
| FaxNumber: | 8022881144 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 TIMBER LN | ||||||||
| Address2: | |||||||||
| City: | SOUTH BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028640521 | ||||||||
| FaxNumber: | 8028646475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2009 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 101.0060740 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1019167 | 05 | VT | MEDICAID |