Provider Demographics
NPI:1831207166
Name:COUSINS, CANDIS JOAN (PAC)
Entity type:Individual
Prefix:
First Name:CANDIS
Middle Name:JOAN
Last Name:COUSINS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HANLEY LANE
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:VT
Mailing Address - Zip Code:05465
Mailing Address - Country:US
Mailing Address - Phone:802-899-9960
Mailing Address - Fax:
Practice Address - Street 1:364 DORSET ST
Practice Address - Street 2:STE 2
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-6270
Practice Address - Country:US
Practice Address - Phone:802-859-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT550030284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
08V151OtherMVP
VT2000061Medicaid