Basic Information
| Provider Information | |||||||||
| NPI: | 1205063492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LESAGE-HORTON | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LESAGE | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 21 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | BRATTLEBORO | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053017110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022583905 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | BRATTLEBORO | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053017110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022583905 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301094661 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 4301094661 | MI | N | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 390200000X | 1056982 | MI | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 042-0012847 | VT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.