Healthcare Provider Details

I. General information

NPI: 1114969565
Provider Name (Legal Business Name): TAMMY D. VACHINO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

PO BOX 32861 ANESTHESIA SERVICES - 5TH FL SURGERY TOWER
CHARLOTTE NC
28232-2861
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-8983
  • Fax: 704-355-8994
Mailing address:
  • Phone: 704-355-8983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number111139
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: