Basic Information
| Provider Information | |||||||||
| NPI: | 1649357385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAE LARSEN | ||||||||
| FirstName: | LESLEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NMW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 81 MEDICAL VILLAGE DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023344110 | ||||||||
| FaxNumber: | 8023344113 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 MEDICAL VILLAGE DR | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | NEWPORT | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058559835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023344110 | ||||||||
| FaxNumber: | 8023344113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| 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 | 367A00000X | 1010030803 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 78119 | 01 | VT | MVP | OTHER | 00068564 | 01 | VT | BLUE SHIELD OF VERMONT | OTHER | 8000748 | 01 | VT | LADIES FIRST | OTHER |