Provider Demographics
NPI:1699711168
Name:GORHAM, ANN MARIE (APRN)
Entity type:Individual
Prefix:
First Name:ANN MARIE
Middle Name:
Last Name:GORHAM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301
Mailing Address - Country:US
Mailing Address - Phone:802-251-9965
Mailing Address - Fax:802-257-8834
Practice Address - Street 1:21 BELMONT AVE STE 1
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6762
Practice Address - Country:US
Practice Address - Phone:802-251-9965
Practice Address - Fax:802-257-8834
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2269517363LA2200X
VT1010030543363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3120196Medicaid
VT6702289Medicaid