Provider Demographics
NPI:1144955733
Name:HARTMAN, MIA CAMILLE
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:CAMILLE
Last Name:HARTMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:CAMILLE
Other - Last Name:MORRISOIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1448 IRISH HILL RD
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:VT
Mailing Address - Zip Code:05847-9756
Mailing Address - Country:US
Mailing Address - Phone:802-272-4631
Mailing Address - Fax:
Practice Address - Street 1:1448 IRISH HILL RD
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:VT
Practice Address - Zip Code:05847-9756
Practice Address - Country:US
Practice Address - Phone:802-272-4631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE114248363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty