Provider Demographics
NPI:1417584608
Name:GRENOBLE, KATHRYN (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:GRENOBLE
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 1:375 NORTH AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-2951
Mailing Address - Country:US
Mailing Address - Phone:413-822-9102
Mailing Address - Fax:
Practice Address - Street 1:37 HAYSTACK RD
Practice Address - Street 2:
Practice Address - City:HINESBURG
Practice Address - State:VT
Practice Address - Zip Code:05461-6613
Practice Address - Country:US
Practice Address - Phone:802-847-4322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0017144207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program