Provider Demographics
NPI:1972741247
Name:KING, MARY (RN, BSN, IBCLC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:RN, BSN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 619
Mailing Address - Street 2:
Mailing Address - City:BARTON
Mailing Address - State:VT
Mailing Address - Zip Code:05822-0619
Mailing Address - Country:US
Mailing Address - Phone:802-535-2011
Mailing Address - Fax:
Practice Address - Street 1:200 INGERSOLL LN
Practice Address - Street 2:
Practice Address - City:BARTON
Practice Address - State:VT
Practice Address - Zip Code:05822-8647
Practice Address - Country:US
Practice Address - Phone:802-535-2011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-26
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224128163WL0100X
VT0260080347163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant