Provider Demographics
NPI:1417318791
Name:PAVELOCK, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:PAVELOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MOUNTAIN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-5967
Mailing Address - Country:US
Mailing Address - Phone:802-655-2536
Mailing Address - Fax:802-655-2629
Practice Address - Street 1:66 MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-5967
Practice Address - Country:US
Practice Address - Phone:802-655-2536
Practice Address - Fax:802-655-2629
Is Sole Proprietor?:No
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0003293183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT033.0003293OtherVT RPH LICENSE