Provider Demographics
NPI:1104290915
Name:VAILLANCOURT, MARY JILL (CRNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JILL
Last Name:VAILLANCOURT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:107 INSTITUTE ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6628
Mailing Address - Country:US
Mailing Address - Phone:716-484-4334
Mailing Address - Fax:833-974-2029
Practice Address - Street 1:107 INSTITUTE ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6628
Practice Address - Country:US
Practice Address - Phone:716-484-4334
Practice Address - Fax:833-974-2029
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASP015710363L00000X, 363LA2200X, 363LG0600X
NYF307302363LA2200X
PARN578441163W00000X
NY362456163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse