Basic Information
Provider Information | |||||||||
NPI: | 1750415063 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HYNES | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 393 TWIN PEAKS RD | ||||||||
Address2: |   | ||||||||
City: | WATERBURY CENTER | ||||||||
State: | VT | ||||||||
PostalCode: | 056777059 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8022448405 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 111 COLCHESTER AVE | ||||||||
Address2: | RHEUMATOLOGY ACC 5TH FLOOR | ||||||||
City: | BURLINGTON | ||||||||
State: | VT | ||||||||
PostalCode: | 054011473 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8028474574 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2007 | ||||||||
LastUpdateDate: | 09/03/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 0600002821 | VT | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207RR0500X | 0420011649 | VT | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
ID | Type | State | Issuer | Description | 1015498 | 05 | VT |   | MEDICAID |