Basic Information
| Provider Information | |||||||||
| NPI: | 1215364062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAREVAAG | ||||||||
| FirstName: | KARYN | ||||||||
| MiddleName: | HARVEY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 30 | ||||||||
| Address2: | |||||||||
| City: | GREAT BARRINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4135289311 | ||||||||
| FaxNumber: | 4136440274 | ||||||||
| Practice Location | |||||||||
| Address1: | 353 BLAIR PARK RD | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054957530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028471470 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2013 | ||||||||
| LastUpdateDate: | 02/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 101-0134554 | VT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 101-0134554 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 265605 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | RN265605 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 110098110A | 05 | MA | MEDICAID |