Healthcare Provider Details

I. General information

NPI: 1851976690
Provider Name (Legal Business Name): CORINNE GRACE VACCARO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 DOCTOR CIR
COLUMBIA SC
29203-6502
US

IV. Provider business mailing address

111 DOCTOR CIR
COLUMBIA SC
29203-6502
US

V. Phone/Fax

Practice location:
  • Phone: 800-491-0909
  • Fax:
Mailing address:
  • Phone: 800-491-0909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25167
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: