Healthcare Provider Details

I. General information

NPI: 1821848946
Provider Name (Legal Business Name): MARYANNE VACA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2024
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N FLAMINGO RD
PEMBROKE PINES FL
33028-1006
US

IV. Provider business mailing address

4465 SW 160TH AVE APT 206
MIRAMAR FL
33027-5734
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-4461
  • Fax:
Mailing address:
  • Phone: 305-316-9589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: