Provider Demographics
NPI:1619133683
Name:WESSEL KISSENBERTH, NANETTE M (DO)
Entity Type:Individual
Prefix:
First Name:NANETTE
Middle Name:M
Last Name:WESSEL KISSENBERTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:NANETTE
Other - Middle Name:
Other - Last Name:KISSENBERTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-496-3838
Mailing Address - Fax:802-496-5586
Practice Address - Street 1:859 OLD COUNTY RD
Practice Address - Street 2:
Practice Address - City:WAITSFIELD
Practice Address - State:VT
Practice Address - Zip Code:05673-6221
Practice Address - Country:US
Practice Address - Phone:802-496-3838
Practice Address - Fax:802-496-5586
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08405700207Q00000X
VT032.0073723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1018957Medicaid
VTY400194057Medicare PIN