Provider Demographics
NPI:1164418059
Name:VAINE, ALICE J (NPC)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:J
Last Name:VAINE
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:242 GREEN ST
Mailing Address - Street 2:DEPT. OF SURGERY
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1336
Mailing Address - Country:US
Mailing Address - Phone:978-630-6267
Mailing Address - Fax:978-630-6596
Practice Address - Street 1:242 GREEN ST
Practice Address - Street 2:DEPT. OF SURGERY
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1336
Practice Address - Country:US
Practice Address - Phone:978-630-6267
Practice Address - Fax:978-630-6596
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA165352363LF0000X, 364SE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SE0003XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA99962Medicare ID - Type Unspecified
MANP430801Medicare UPIN
NP4308Medicare UPIN
MAUX3181Medicare UPIN