Provider Demographics
NPI:1750415063
Name:HYNES, NICOLE R (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:R
Last Name:HYNES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:393 TWIN PEAKS RD
Mailing Address - Street 2:
Mailing Address - City:WATERBURY CENTER
Mailing Address - State:VT
Mailing Address - Zip Code:05677-7059
Mailing Address - Country:US
Mailing Address - Phone:802-244-8405
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:RHEUMATOLOGY ACC 5TH FLOOR
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-4574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0600002821390200000X
VT0420011649207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1015498Medicaid