Healthcare Provider Details

I. General information

NPI: 1992674071
Provider Name (Legal Business Name): ALYSSA ANN VACCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2025
Last Update Date: 11/05/2025
Certification Date: 11/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 SOUTHWOOD BLVD STE 101
INCLINE VILLAGE NV
89451-7401
US

IV. Provider business mailing address

1401 TIPTOP TRL
PAHRUMP NV
89048-5479
US

V. Phone/Fax

Practice location:
  • Phone: 702-772-9745
  • Fax:
Mailing address:
  • Phone: 541-214-0209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: