Healthcare Provider Details

I. General information

NPI: 1003363722
Provider Name (Legal Business Name): DEBRA VACCARO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2016
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 COMANCHE RD NE STE C
ALBUQUERQUE NM
87107-4546
US

IV. Provider business mailing address

4374 NEW TOWN AVE STE 102
WILLIAMSBURG VA
23188-2865
US

V. Phone/Fax

Practice location:
  • Phone: 505-998-7200
  • Fax: 505-998-7220
Mailing address:
  • Phone: 757-259-6770
  • Fax: 757-259-6794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024173928
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: