Provider Demographics
NPI:1346288834
Name:FLETCHER MAINE, PAMELA LOUISE (PT)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:LOUISE
Last Name:FLETCHER MAINE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:LOUISE
Other - Last Name:FLETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:5468 MAIN ST
Mailing Address - Street 2:PO BOX 1224
Mailing Address - City:MANCHESTER CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05255-9481
Mailing Address - Country:US
Mailing Address - Phone:802-362-2126
Mailing Address - Fax:802-362-4884
Practice Address - Street 1:5468 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER CENTER
Practice Address - State:VT
Practice Address - Zip Code:05255-9481
Practice Address - Country:US
Practice Address - Phone:802-362-2126
Practice Address - Fax:802-362-4884
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0093531225100000X
VT0400089086225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02018880Medicaid
NYQ51001Medicare ID - Type Unspecified