Provider Demographics
NPI:1982659132
Name:BRISTOL, MARLENE M (ARNP)
Entity Type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:M
Last Name:BRISTOL
Suffix:
Gender:F
Credentials:ARNP
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 A
Mailing Address - Street 2:
Mailing Address - City:EAST CORINTH
Mailing Address - State:VT
Mailing Address - Zip Code:05040-0900
Mailing Address - Country:US
Mailing Address - Phone:802-757-2325
Mailing Address - Fax:
Practice Address - Street 1:65 MAIN ST N
Practice Address - Street 2:
Practice Address - City:WELLS RIVER
Practice Address - State:VT
Practice Address - Zip Code:05081-9692
Practice Address - Country:US
Practice Address - Phone:802-757-2325
Practice Address - Fax:802-757-3215
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010020753363L00000X
NH0370502303363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0NP1026Medicaid
VT500012460OtherRAIL ROAD MEDICARE
S52646Medicare UPIN
VT500012460OtherRAIL ROAD MEDICARE
VTS52646Medicare PIN
VTNP1026Medicare PIN
VT0NP1026Medicaid