Provider Demographics
NPI:1255492369
Name:NICKERSON, ELIZABETH K (MD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:K
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COLCHESTER AVE
Mailing Address - Street 2:FAHC
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401
Mailing Address - Country:US
Mailing Address - Phone:802-847-3333
Mailing Address - Fax:802-847-1424
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:FAHC
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-3333
Practice Address - Fax:802-847-1424
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2172062084P0800X
VT04200126252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry