Provider Demographics
NPI:1194486357
Name:MACKSOUD, KATHRYN ANNE
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:MACKSOUD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:WEST LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03784
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 RIVER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-2930
Practice Address - Country:US
Practice Address - Phone:802-886-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-09
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT055.0031598363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program