Provider Demographics
NPI:1033114632
Name:VAILLANT, ANNE L (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:L
Last Name:VAILLANT
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:LIBERTY
Other - Last Name:VAILLANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM
Mailing Address - Street 1:17 RESEARCH DRIVE
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002
Mailing Address - Country:US
Mailing Address - Phone:413-549-8400
Mailing Address - Fax:413-549-8409
Practice Address - Street 1:17 RESEARCH DRIVE
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002
Practice Address - Country:US
Practice Address - Phone:413-549-8400
Practice Address - Fax:413-549-8409
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA206006367A00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110017490AMedicaid
1004760001Medicare NSC
MARN0241Medicare PIN
P82946Medicare UPIN