Provider Demographics
NPI:1972369387
Name:FETTER, MICHAEL DIETRICH (MS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DIETRICH
Last Name:FETTER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 CAMBRIDGEVILLE DR UNIT 4
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:NH
Mailing Address - Zip Code:03748-3160
Mailing Address - Country:US
Mailing Address - Phone:603-345-6578
Mailing Address - Fax:
Practice Address - Street 1:11 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1126
Practice Address - Country:US
Practice Address - Phone:802-728-4466
Practice Address - Fax:802-728-4197
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker