Provider Demographics
NPI:1720003692
Name:GIANNONI, MARY ALICE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:GIANNONI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 S PASTURE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-7359
Mailing Address - Country:US
Mailing Address - Phone:802-985-3131
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-8200
Practice Address - Fax:802-847-5364
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010009653363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTONP1064Medicaid
S54401Medicare UPIN
VTONP1064Medicaid