Provider Demographics
NPI:1801208418
Name:DACEK, KIM NICOLE
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:NICOLE
Last Name:DACEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:NICOLE
Other - Last Name:TANTLINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:875 ROOSEVELT HWY STE 132
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-4460
Mailing Address - Country:US
Mailing Address - Phone:802-864-7483
Mailing Address - Fax:802-660-4337
Practice Address - Street 1:875 ROOSEVELT HWY STE 132
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-4460
Practice Address - Country:US
Practice Address - Phone:802-864-7483
Practice Address - Fax:802-660-4337
Is Sole Proprietor?:No
Enumeration Date:2014-05-30
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0107576363LF0000X
MARN2284328163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse