Provider Demographics
NPI:1699151266
Name:LAROCHELLE, KELLIE (PA)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:LAROCHELLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 OLCOTT DR
Mailing Address - Street 2:SUITE U3
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-9601
Mailing Address - Country:US
Mailing Address - Phone:802-295-6132
Mailing Address - Fax:802-295-1358
Practice Address - Street 1:331 OLCOTT DR
Practice Address - Street 2:SUITE U3
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-9601
Practice Address - Country:US
Practice Address - Phone:802-295-6132
Practice Address - Fax:802-295-1358
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant