Provider Demographics
NPI:1962906909
Name:DETWEILER, KERRY E (RD)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:E
Last Name:DETWEILER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5024 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05462-9724
Mailing Address - Country:US
Mailing Address - Phone:518-488-8132
Mailing Address - Fax:
Practice Address - Street 1:5024 MAIN RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:VT
Practice Address - Zip Code:05462-9724
Practice Address - Country:US
Practice Address - Phone:518-488-8132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT104.01169012255A2300X
VT074.0131360133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer