Provider Demographics
NPI:1568482917
Name:SHEA-VAILLANCOURT, JUDITH A (CFNP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:A
Last Name:SHEA-VAILLANCOURT
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 CENTRAL ST
Mailing Address - Street 2:STE 116
Mailing Address - City:FOXBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02035
Mailing Address - Country:US
Mailing Address - Phone:508-543-6306
Mailing Address - Fax:508-543-2976
Practice Address - Street 1:132 CENTRAL ST
Practice Address - Street 2:STE 116
Practice Address - City:FOXBORO
Practice Address - State:MA
Practice Address - Zip Code:02035
Practice Address - Country:US
Practice Address - Phone:508-543-6306
Practice Address - Fax:508-543-2976
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA142123NP208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP9881OtherBLUE CROSS BLUE SHIELD