Provider Demographics
NPI:1508297599
Name:FISK, CONNIE (NP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:FISK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4560
Mailing Address - Country:US
Mailing Address - Phone:802-747-1857
Mailing Address - Fax:802-747-0129
Practice Address - Street 1:1 COMMONS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4652
Practice Address - Country:US
Practice Address - Phone:802-747-1857
Practice Address - Fax:802-747-1026
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0134648363LP0808X
NYF401672363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03772176Medicaid
NY03772176Medicaid