Provider Demographics
NPI:1407974223
Name:VAILLANCOURT, MONIQUE (MSN, NP)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:MSN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 WESTWOOD PLZ
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-1703
Mailing Address - Country:US
Mailing Address - Phone:310-794-7919
Mailing Address - Fax:
Practice Address - Street 1:221 WESTWOOD PLZ
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-1703
Practice Address - Country:US
Practice Address - Phone:310-794-7919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARNP11874363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care