Provider Demographics
NPI:1215941687
Name:COLLETTE, MARIA LEE (PA)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:LEE
Last Name:COLLETTE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:LEE
Other - Last Name:TARDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 PORTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05753
Mailing Address - Country:US
Mailing Address - Phone:802-388-8808
Mailing Address - Fax:802-388-8322
Practice Address - Street 1:10 NORTH STREET
Practice Address - Street 2:LITTLE CITY FAMILY PRACTICE
Practice Address - City:VERGENES
Practice Address - State:VT
Practice Address - Zip Code:05491
Practice Address - Country:US
Practice Address - Phone:802-877-3466
Practice Address - Fax:802-877-1188
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030782363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant