Basic Information
| Provider Information | |||||||||
| NPI: | 1700840600 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KYBURZ-LADUE | ||||||||
| FirstName: | MARYANNE | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 BLAIR PARK RD | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054957586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028724343 | ||||||||
| FaxNumber: | 8028720282 | ||||||||
| Practice Location | |||||||||
| Address1: | 789 PINE ST | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054014933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028640693 | ||||||||
| FaxNumber: | 8028606613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 06/06/2013 | ||||||||
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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 | 136A00000X | 074-0000127 | VT | Y | Dietary & Nutritional Service Providers | Dietetic Technician, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1008797 | 05 | VT | MEDICAID |