Provider Demographics
NPI:1700840600
Name:KYBURZ-LADUE, MARYANNE (RD)
Entity Type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:KYBURZ-LADUE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BLAIR PARK RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-7586
Mailing Address - Country:US
Mailing Address - Phone:802-872-4343
Mailing Address - Fax:802-872-0282
Practice Address - Street 1:789 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4933
Practice Address - Country:US
Practice Address - Phone:802-864-0693
Practice Address - Fax:802-860-6613
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT074-0000127136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1008797Medicaid
VTMT003701Medicare PIN