Provider Demographics
NPI:1972039147
Name:KICHURA, JEANINE MANISCALCO (DPT)
Entity Type:Individual
Prefix:DR
First Name:JEANINE
Middle Name:MANISCALCO
Last Name:KICHURA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:JEANINE
Other - Middle Name:FRANCES
Other - Last Name:MANISCALCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:HUNTER
Mailing Address - State:NY
Mailing Address - Zip Code:12442-0564
Mailing Address - Country:US
Mailing Address - Phone:518-965-3476
Mailing Address - Fax:
Practice Address - Street 1:3 CHAMPLAIN CMNS STE 1
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-1563
Practice Address - Country:US
Practice Address - Phone:802-524-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040.0130674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist