Provider Demographics
NPI:1457658221
Name:LIGHTBODY, KAITLYN (NNP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:LIGHTBODY
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 TUTTLE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-4106
Mailing Address - Country:US
Mailing Address - Phone:802-233-6991
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-2370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0073830363LN0005X
MECNP161222363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care