Healthcare Provider Details

I. General information

NPI: 1588460208
Provider Name (Legal Business Name): SHANINE VACA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2025
Last Update Date: 02/22/2025
Certification Date: 02/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23039 WATERGATE CIR
BOCA RATON FL
33428-5627
US

IV. Provider business mailing address

23039 WATERGATE CIR
BOCA RATON FL
33428-5627
US

V. Phone/Fax

Practice location:
  • Phone: 561-900-8813
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number7395
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: