Basic Information
| Provider Information | |||||||||
| NPI: | 1912010505 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LADUE | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LADUE-WEBER | ||||||||
| OtherFirstName: | KIM | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | ATT: CVMC FINANCE DEPT | ||||||||
| City: | BARRE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056410547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022255660 | ||||||||
| FaxNumber: | 8022299533 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 FISHER RD | ||||||||
| Address2: | MOB-A SUITE 2-1 | ||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056029516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022255660 | ||||||||
| FaxNumber: | 8022299533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 11/24/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1010013563 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | 1010013563 | VT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1010501 | 05 | VT | MEDICAID |