Provider Demographics
NPI:1740675065
Name:PIERCE, KELSEY LANGE (PA-C)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:LANGE
Last Name:PIERCE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HOSPITAL DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-5009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 HOSPITAL DR
Practice Address - Street 2:SUITE 111
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-5009
Practice Address - Country:US
Practice Address - Phone:802-440-4077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant