Provider Demographics
NPI:1912010505
Name:LADUE, KIM A (FNP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:A
Last Name:LADUE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:A
Other - Last Name:LADUE-WEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:ATT: CVMC FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-225-5660
Mailing Address - Fax:802-229-9533
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:MOB-A SUITE 2-1
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-225-5660
Practice Address - Fax:802-229-9533
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010013563363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010501Medicaid
VTNP493201Medicare PIN
VTNP493202Medicare PIN
VT1010501Medicaid
VTNP493201OtherMEDICARE PTAN