Provider Demographics
NPI:1124357215
Name:MACAULAY, LEAH MARIETTE (PNP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:MARIETTE
Last Name:MACAULAY
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:MARIETTE
Other - Last Name:PORTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:600 BLAIR PARK RD STE 285
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7586
Mailing Address - Country:US
Mailing Address - Phone:802-288-1140
Mailing Address - Fax:802-288-1144
Practice Address - Street 1:51 TIMBER LN
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403
Practice Address - Country:US
Practice Address - Phone:802-864-0521
Practice Address - Fax:802-864-6475
Is Sole Proprietor?:No
Enumeration Date:2009-12-18
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0060740363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1019167Medicaid