Basic Information
| Provider Information | |||||||||
| NPI: | 1487691614 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOULETTE | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 LAVOIE DR | ||||||||
| Address2: | |||||||||
| City: | ESSEX JUNCTION | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054524435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028723132 | ||||||||
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| Practice Location | |||||||||
| Address1: | 617 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054011601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028646309 | ||||||||
| FaxNumber: | 8028604324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0550030759 | VT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4148045 | 01 | MVP | OTHER | 69121 | 01 | VERMONT MANAGED CARE | OTHER | 9000250 | 05 | VT | MEDICAID | 0030759 | 01 | VT | FLETCHER ALLEN PREFERRED | OTHER | 69121 | 01 | BLUE CROSS BLUE SHIELD | OTHER |