Provider Demographics
NPI:1982763306
Name:VAILLANCOURT, ANNE THERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:THERESA
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63362
Mailing Address - Street 2:151 RAM'S PLAZA
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3362
Mailing Address - Country:US
Mailing Address - Phone:919-620-4918
Mailing Address - Fax:919-620-4921
Practice Address - Street 1:1728 FORDHAM BLVD
Practice Address - Street 2:151 RAM'S PLAZA
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-2397
Practice Address - Country:US
Practice Address - Phone:919-968-1985
Practice Address - Fax:919-942-0038
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100680363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC100680OtherMEDICAL LICENSE
NC100680OtherMEDICAL LICENSE