Healthcare Provider Details

I. General information

NPI: 1801078340
Provider Name (Legal Business Name): CONSTANCE MARIE VACCAREZZA PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2007
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6421 S BURSON RD
VALLEY SPRINGS CA
95252-8909
US

IV. Provider business mailing address

6421 S BURSON RD
VALLEY SPRINGS CA
95252-8909
US

V. Phone/Fax

Practice location:
  • Phone: 209-772-3192
  • Fax:
Mailing address:
  • Phone: 209-772-3192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number384667
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: