Healthcare Provider Details

I. General information

NPI: 1194122937
Provider Name (Legal Business Name): PATRICIA VASSALLO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2014
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE
JBER AK
99506-3702
US

IV. Provider business mailing address

5955 ZEAMER AVE
JBER AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-2907
  • Fax:
Mailing address:
  • Phone: 907-580-2907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP027691
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704268599
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71016443A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: