Basic Information
| Provider Information | |||||||||
| NPI: | 1619133683 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESSEL KISSENBERTH | ||||||||
| FirstName: | NANETTE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KISSENBERTH | ||||||||
| OtherFirstName: | NANETTE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT | ||||||||
| City: | BARRE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056410547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024963838 | ||||||||
| FaxNumber: | 8024965586 | ||||||||
| Practice Location | |||||||||
| Address1: | 859 OLD COUNTY RD | ||||||||
| Address2: | |||||||||
| City: | WAITSFIELD | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056736221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024963838 | ||||||||
| FaxNumber: | 8024965586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2008 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MB08405700 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 032.0073723 | VT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1018957 | 05 | VT | MEDICAID |