Healthcare Provider Details

I. General information

NPI: 1063910339
Provider Name (Legal Business Name): JESSICA R VACCARO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2018
Last Update Date: 01/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FOREST AVE
BUFFALO NY
14213-1207
US

IV. Provider business mailing address

26 LUDWIG AVE
WEST SENECA NY
14224-2604
US

V. Phone/Fax

Practice location:
  • Phone: 716-816-2162
  • Fax:
Mailing address:
  • Phone: 716-517-1907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number568203
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: