Provider Demographics
NPI:1699269001
Name:VITALE, JILLIAN P (PA-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:P
Last Name:VITALE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:P
Other - Last Name:BOUCHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:119 BELMONT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2903
Practice Address - Country:US
Practice Address - Phone:508-334-6206
Practice Address - Fax:508-334-6083
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4261363A00000X
MAPA6619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant