Healthcare Provider Details

I. General information

NPI: 1669921359
Provider Name (Legal Business Name): MRS. JENNIFER VACCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 E. SPRUCE STREET
TARPON SPRINGS FL
34689
US

IV. Provider business mailing address

612 E. SPRUCE STREET
TARPON SPRINGS FL
34689
US

V. Phone/Fax

Practice location:
  • Phone: 727-580-0131
  • Fax:
Mailing address:
  • Phone: 727-580-0131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA50809
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: