Basic Information
| Provider Information | |||||||||
| NPI: | 1215941687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLETTE | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TARDY | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 104 PORTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023888808 | ||||||||
| FaxNumber: | 8023888322 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 NORTH STREET | ||||||||
| Address2: | LITTLE CITY FAMILY PRACTICE | ||||||||
| City: | VERGENES | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028773466 | ||||||||
| FaxNumber: | 8028771188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| 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 | 363A00000X | 0550030782 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.