Healthcare Provider Details

I. General information

NPI: 1982037040
Provider Name (Legal Business Name): RYAN ELIZABETH VACCAREZZA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 08/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 S FAIRMONT AVE
LODI CA
95240-5118
US

IV. Provider business mailing address

975 FAIRMONT AVE
LODI CA
95242
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-3411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number23294
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: