Healthcare Provider Details

I. General information

NPI: 1609974112
Provider Name (Legal Business Name): VICTORIA ANN VACCARO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA ANN THEISEN FNP

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 KIMOLE LN
ADRIAN MI
49221-1463
US

IV. Provider business mailing address

730 KIMOLE LN
ADRIAN MI
49221-1463
US

V. Phone/Fax

Practice location:
  • Phone: 517-263-6794
  • Fax: 517-263-4275
Mailing address:
  • Phone: 517-263-6794
  • Fax: 517-263-4275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704150960
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704150960
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: