Provider Demographics
NPI:1912341306
Name:CHARLES, LORETTA B (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:B
Last Name:CHARLES
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:ATT: CVMC FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-485-4161
Mailing Address - Fax:802-485-4163
Practice Address - Street 1:87 PAINE MOUNTAIN DRIVE
Practice Address - Street 2:GREEN MOUNTAIN FAMILY PRACTICE
Practice Address - City:NORTHFIELD
Practice Address - State:VT
Practice Address - Zip Code:05663
Practice Address - Country:US
Practice Address - Phone:802-485-4161
Practice Address - Fax:802-485-4163
Is Sole Proprietor?:No
Enumeration Date:2013-04-29
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY33 337930363LF0000X
VT101.00113985363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily