Provider Demographics
NPI:1093741571
Name:MIKIJANIEC, AGNES (ARNP)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:
Last Name:MIKIJANIEC
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BELMONT AVE
Mailing Address - Street 2:ATT'N: MARILYN BOUDREAU
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-6613
Mailing Address - Country:US
Mailing Address - Phone:802-257-8382
Mailing Address - Fax:802-251-8466
Practice Address - Street 1:17 BELMONT AVE
Practice Address - Street 2:ATT'N: MARILYN BOUDREAU
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6613
Practice Address - Country:US
Practice Address - Phone:802-257-8382
Practice Address - Fax:802-251-8466
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT026-0029155363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTONP3598Medicaid
VT68614OtherBLUE SHIELD OF VT
NP3598Medicare ID - Type Unspecified
VT68614OtherBLUE SHIELD OF VT