Provider Demographics
NPI:1831278407
Name:FISH, JOAN L (NPP)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:L
Last Name:FISH
Suffix:
Gender:F
Credentials:NPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:160 BENMONT AVE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-1873
Mailing Address - Country:US
Mailing Address - Phone:802-442-3520
Mailing Address - Fax:802-447-3392
Practice Address - Street 1:160 BENMONT AVE
Practice Address - Street 2:SUITE 20
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-1873
Practice Address - Country:US
Practice Address - Phone:802-442-3520
Practice Address - Fax:802-447-3392
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT1010021334363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012012Medicaid
VT1012012Medicaid