Provider Demographics
NPI:1801673249
Name:AXTELL, KATELIN ELIZABETH IRENE
Entity type:Individual
Prefix:
First Name:KATELIN
Middle Name:ELIZABETH IRENE
Last Name:AXTELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 W MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SHAFTSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05262-9368
Mailing Address - Country:US
Mailing Address - Phone:479-422-3083
Mailing Address - Fax:
Practice Address - Street 1:11 QUARRY HILL RD
Practice Address - Street 2:
Practice Address - City:LEE
Practice Address - State:MA
Practice Address - Zip Code:01238-9645
Practice Address - Country:US
Practice Address - Phone:413-243-0536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2385100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner