Provider Demographics
NPI:1487691614
Name:GOULETTE, KERRY A (PA)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:A
Last Name:GOULETTE
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 1:42 LAVOIE DR
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-4435
Mailing Address - Country:US
Mailing Address - Phone:802-872-3132
Mailing Address - Fax:
Practice Address - Street 1:617 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1601
Practice Address - Country:US
Practice Address - Phone:802-864-6309
Practice Address - Fax:802-860-4324
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030759207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4148045OtherMVP
69121OtherVERMONT MANAGED CARE
VT9000250Medicaid
VT0030759OtherFLETCHER ALLEN PREFERRED
69121OtherBLUE CROSS BLUE SHIELD
69121OtherVERMONT MANAGED CARE
AP2588Medicare ID - Type Unspecified