Basic Information
| Provider Information | |||||||||
| NPI: | 1104290915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAILLANCOURT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JILL | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 E 2ND ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165071537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144568980 | ||||||||
| FaxNumber: | 8144510443 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 E 2ND ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165071537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144568980 | ||||||||
| FaxNumber: | 8144510443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2015 | ||||||||
| LastUpdateDate: | 07/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 362456 | NY | N | Nursing Service Providers | Registered Nurse | 363LA2200X | F307302 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 163W00000X | RN578441 | PA | N | Nursing Service Providers | Registered Nurse | 363LA2200X | SP015710 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LG0600X | SP015710 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | SP015710 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.