Provider Demographics
NPI:1043520448
Name:HUMPHRIES, JENNIFER G (LPN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:HUMPHRIES
Suffix:
Gender:F
Credentials:LPN
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 202
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05667-0202
Mailing Address - Country:US
Mailing Address - Phone:802-454-1915
Mailing Address - Fax:
Practice Address - Street 1:149 SOUTH BAYLEY HAZEN RD.
Practice Address - Street 2:HOME ACRES FARM
Practice Address - City:RYEGATE
Practice Address - State:VT
Practice Address - Zip Code:05042
Practice Address - Country:US
Practice Address - Phone:802-584-4679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT025.0069058164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse