Provider Demographics
NPI:1760020762
Name:VAILLANCOURT, KELLY M
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 WESTMINSTER ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-4766
Mailing Address - Country:US
Mailing Address - Phone:978-345-0685
Mailing Address - Fax:978-829-2210
Practice Address - Street 1:545 WESTMINSTER ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-4766
Practice Address - Country:US
Practice Address - Phone:978-345-0685
Practice Address - Fax:978-829-2210
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator