Provider Demographics
NPI:1598741019
Name:VANDERVORT, ELISA BRETTLER (FNP, CNM)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:BRETTLER
Last Name:VANDERVORT
Suffix:
Gender:F
Credentials:FNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CVMC FAMILY MEDICINE - BERLIN
Mailing Address - Street 2:246 GRANGER ROAD SUITE 2
Mailing Address - City:BERLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:246 GRANGER RD STE 2
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602
Practice Address - Country:US
Practice Address - Phone:802-225-5810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0026277367A00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0NP4077Medicaid
VT0NP4077Medicaid
VTP80399Medicare UPIN
VTNP407701Medicare PIN