Provider Demographics
NPI:1972680619
Name:DOUGLAS, PRISCILLA (MS)
Entity Type:Individual
Prefix:MS
First Name:PRISCILLA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4523
Mailing Address - Country:US
Mailing Address - Phone:802-658-9943
Mailing Address - Fax:
Practice Address - Street 1:FANNY ALLEN AUDIOLOGY
Practice Address - Street 2:790 COLLEGE PARKWAY
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446
Practice Address - Country:US
Practice Address - Phone:802-847-3970
Practice Address - Fax:802-847-5880
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1003541Medicaid
VTVN2357Medicare ID - Type Unspecified