Basic Information
| Provider Information | |||||||||
| NPI: | 1588989016 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONNOLLY | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | VAN WOERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 KNIGHT LN STE 10 | ||||||||
| Address2: | |||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054959308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028724343 | ||||||||
| FaxNumber: | 8022881144 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 HAYDENBERRY DR STE 41 | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054683848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028931200 | ||||||||
| FaxNumber: | 8028932756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2010 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 042.0012649 | VT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1021912 | 05 | VT | MEDICAID |