Provider Demographics
NPI:1528030038
Name:KEARNEY, MICHELLE KATHLEEN (PA C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:KATHLEEN
Last Name:KEARNEY
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:KATHLEEN
Other - Last Name:BANBURY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1063
Mailing Address - Street 2:FLETCHER ALLEN HEALTH CARE
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05402-1063
Mailing Address - Country:US
Mailing Address - Phone:802-847-4590
Mailing Address - Fax:802-847-0654
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:FLETCHER ALLEN HEALTH CARE NEUROSURGERY
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-4590
Practice Address - Fax:802-847-0654
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000237Medicaid
Q09448Medicare UPIN
VT9000237Medicaid