Provider Demographics
NPI:1083658058
Name:VILLEMAIRE, LEAH TERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:TERESA
Last Name:VILLEMAIRE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 MOUNTAIN VIEW DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-5988
Mailing Address - Country:US
Mailing Address - Phone:802-864-0192
Mailing Address - Fax:802-860-4919
Practice Address - Street 1:354 MOUNTAIN VIEW DR
Practice Address - Street 2:SUITE 300
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5988
Practice Address - Country:US
Practice Address - Phone:802-864-0192
Practice Address - Fax:802-860-4919
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT005-0031072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0011500OtherMEDICARE