Provider Demographics
NPI:1841503935
Name:GRACE, KIRSTEN BERGEN (APRN)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:BERGEN
Last Name:GRACE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 905
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-0905
Mailing Address - Country:US
Mailing Address - Phone:802-748-8141
Mailing Address - Fax:802-748-4098
Practice Address - Street 1:1315 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9210
Practice Address - Country:US
Practice Address - Phone:802-748-8141
Practice Address - Fax:802-748-4098
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT88494163W00000X
NH076241-23363LF0000X
CT004399363LF0000X
VT101-0118108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004399OtherSTATE LICENSE