Provider Demographics
NPI:1235463092
Name:SHUTTER, KELLE RAE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLE
Middle Name:RAE
Last Name:SHUTTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLE
Other - Middle Name:RAE
Other - Last Name:HERNING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
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 1:21 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-7110
Practice Address - Country:US
Practice Address - Phone:802-258-3905
Practice Address - Fax:802-258-4903
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60500534208000000X, 208000000X
VT042.0015262208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT6706620Medicaid
NH3127306Medicaid