Provider Demographics
NPI:1649227877
Name:FANTELLI, KERRY N (PA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:N
Last Name:FANTELLI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:
Other - Last Name:MORUTHANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:74 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-6224
Mailing Address - Country:US
Mailing Address - Phone:802-863-7913
Mailing Address - Fax:
Practice Address - Street 1:617 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1601
Practice Address - Country:US
Practice Address - Phone:802-864-6309
Practice Address - Fax:802-860-4324
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030723207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT4141802OtherMVP
VT58727OtherBLUE CROSS BLUE SHIELD
VT9000147Medicaid
VT58727OtherVERMONT MANAGED CARE
VT58727OtherBLUE CROSS BLUE SHIELD
P56991Medicare UPIN