Healthcare Provider Details

I. General information

NPI: 1790492668
Provider Name (Legal Business Name): LUCIA R VASSALLO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 METCALF DRIVE
AUBURN NY
13021
US

IV. Provider business mailing address

52 METCALF DRIVE
AUBURN NY
13021
US

V. Phone/Fax

Practice location:
  • Phone: 315-255-8609
  • Fax: 315-282-2805
Mailing address:
  • Phone: 315-255-8609
  • Fax: 315-282-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number738474
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: