Provider Demographics
NPI:1619992559
Name:PACKARD, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:PACKARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 NORWICH AVE
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:VT
Mailing Address - Zip Code:05088
Mailing Address - Country:US
Mailing Address - Phone:802-295-2420
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-1000
Practice Address - Country:US
Practice Address - Phone:603-650-4897
Practice Address - Fax:603-650-4560
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHH475237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30432930Medicaid
VT1010488Medicaid