Healthcare Provider Details

I. General information

NPI: 1003252073
Provider Name (Legal Business Name): DORIS YANETH VACA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DORIS YANETH OEFELEIN

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 05/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 E BROADWAY
MONTICELLO NY
12701-8802
US

IV. Provider business mailing address

147 E BROADWAY
MONTICELLO NY
12701-8802
US

V. Phone/Fax

Practice location:
  • Phone: 845-866-2511
  • Fax:
Mailing address:
  • Phone: 845-866-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number649357-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: