Basic Information
| Provider Information | |||||||||
| NPI: | 1699711168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORHAM | ||||||||
| FirstName: | ANN MARIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | BRATTLEBORO | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022519965 | ||||||||
| FaxNumber: | 8022578834 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 BELMONT AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | BRATTLEBORO | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053016762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022519965 | ||||||||
| FaxNumber: | 8022578834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN2269517 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 1010030543 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3120196 | 05 | NH | MEDICAID | 6702289 | 05 | VT | MEDICAID |