Provider Demographics
NPI:1053307918
Name:PEZZULICH, ALICE CECILE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:CECILE
Last Name:PEZZULICH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:CECILE
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:9 CHURCH STREET
Mailing Address - Street 2:PO BOX 690
Mailing Address - City:ARLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05250-0690
Mailing Address - Country:US
Mailing Address - Phone:802-375-6566
Mailing Address - Fax:802-375-6828
Practice Address - Street 1:9 CHURCH ST.
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05250
Practice Address - Country:US
Practice Address - Phone:802-375-6566
Practice Address - Fax:802-375-6828
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0027640163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTONP4075Medicaid
VT00059357OtherVERMONT BLUE CROSS
GONP4075OtherCHAMPUS/TRICARE
414900OtherCIGNA
VT0473830Medicaid
696890OtherMVP HEALTHPLAN
GONP4075OtherPALMETTO GBA
473830Medicare Oscar/Certification
GONP4075OtherPALMETTO GBA
VT1053307918Medicare PIN
414900OtherCIGNA
696890OtherMVP HEALTHPLAN