Basic Information
| Provider Information | |||||||||
| NPI: | 1912341306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARLES | ||||||||
| FirstName: | LORETTA | ||||||||
| MiddleName: | B. | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 547 | ||||||||
| Address2: | ATT: CVMC FINANCE DEPT | ||||||||
| City: | BARRE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056410547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024854161 | ||||||||
| FaxNumber: | 8024854163 | ||||||||
| Practice Location | |||||||||
| Address1: | 87 PAINE MOUNTAIN DRIVE | ||||||||
| Address2: | GREEN MOUNTAIN FAMILY PRACTICE | ||||||||
| City: | NORTHFIELD | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024854161 | ||||||||
| FaxNumber: | 8024854163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2013 | ||||||||
| LastUpdateDate: | 08/25/2015 | ||||||||
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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 | 363LF0000X | 33 337930 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 101.00113985 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.