Provider Demographics
NPI:1497460554
Name:EDWARDS, MARY KATHRYN (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 FOSTER FARM RD
Mailing Address - Street 2:
Mailing Address - City:STOWE
Mailing Address - State:VT
Mailing Address - Zip Code:05672-5073
Mailing Address - Country:US
Mailing Address - Phone:706-338-7948
Mailing Address - Fax:
Practice Address - Street 1:70 S WINOOSKI AVE STE 2C
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3969
Practice Address - Country:US
Practice Address - Phone:802-861-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT074.0134384133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1234567Medicaid