Healthcare Provider Details

I. General information

NPI: 1790543718
Provider Name (Legal Business Name): GIANNA VACCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 WASHINGTON AVE
KINGSTON NY
12401-3702
US

IV. Provider business mailing address

80 GRANDEVILLE CT APT 1232
WAKEFIELD RI
02879-8215
US

V. Phone/Fax

Practice location:
  • Phone: 845-338-7410
  • Fax:
Mailing address:
  • Phone: 401-680-2043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number034809
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: