Provider Demographics
NPI:1811403033
Name:VAILLANCOURT, ANTONIETTA E (PA)
Entity Type:Individual
Prefix:
First Name:ANTONIETTA
Middle Name:E
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANTONIETTA
Other - Middle Name:E
Other - Last Name:IOSUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23600 ROLLING FORK WAY
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20882-2808
Mailing Address - Country:US
Mailing Address - Phone:301-641-8354
Mailing Address - Fax:
Practice Address - Street 1:9561 WHITE PILLAR TER
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20882-2816
Practice Address - Country:US
Practice Address - Phone:301-641-8354
Practice Address - Fax:301-641-8354
Is Sole Proprietor?:No
Enumeration Date:2017-12-26
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06707363AS0400X
HIAMD-789363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical