Provider Demographics
NPI:1568479814
Name:NICKERSON, KRISTA ROXANN (CNM)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:ROXANN
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4302
Mailing Address - Country:US
Mailing Address - Phone:802-881-8804
Mailing Address - Fax:
Practice Address - Street 1:353 BLAIR PARK RD
Practice Address - Street 2:WOMEN'S HEALTH SERVICE
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-7530
Practice Address - Country:US
Practice Address - Phone:802-847-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0025978367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012201Medicaid
VTVN3919Medicare ID - Type Unspecified
VT1012201Medicaid