Basic Information
Provider Information | |||||||||
NPI: | 1891196804 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAYWOOD | ||||||||
FirstName: | THERESA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 71 ALLEN ST | ||||||||
Address2: | STE 403 | ||||||||
City: | RUTLAND | ||||||||
State: | VT | ||||||||
PostalCode: | 057014570 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8027724414 | ||||||||
FaxNumber: | 8027727973 | ||||||||
Practice Location | |||||||||
Address1: | 275 ROUTE 30 N | ||||||||
Address2: |   | ||||||||
City: | BOMOSEEN | ||||||||
State: | VT | ||||||||
PostalCode: | 057329647 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8024685641 | ||||||||
FaxNumber: | 8024682923 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/09/2014 | ||||||||
LastUpdateDate: | 12/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 101.0103560 | VT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LF0000X | 101.0103560 | VT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 1023840 | 05 | VT |   | MEDICAID |