Provider Demographics
NPI:1821084302
Name:DERRY, ELIZABETH A (RD, CD, CDE)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:DERRY
Suffix:
Gender:F
Credentials:RD, CD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:289 COUNTY RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VT
Mailing Address - Zip Code:05089-9000
Mailing Address - Country:US
Mailing Address - Phone:802-674-7300
Mailing Address - Fax:802-674-7314
Practice Address - Street 1:289 COUNTY RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VT
Practice Address - Zip Code:05089-9000
Practice Address - Country:US
Practice Address - Phone:802-674-7300
Practice Address - Fax:802-674-7314
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT074-0000187133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTMT0701Medicare PIN