Healthcare Provider Details

I. General information

NPI: 1912908484
Provider Name (Legal Business Name): KIM ANN VITACCO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date: 04/28/2022
Reactivation Date: 06/14/2022

III. Provider practice location address

KIM A VITACCO ANP-C 2 SHELTER HARBOR COURT
WADING RIVER NY
11792-2202
US

IV. Provider business mailing address

KIM A VITACCO ANP-C 2 SHELTER HARBOR COURT
WADING RIVER NY
11792-2202
US

V. Phone/Fax

Practice location:
  • Phone: 631-886-1668
  • Fax: 631-886-1909
Mailing address:
  • Phone: 631-886-1668
  • Fax: 631-886-1909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF303866
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: