Provider Demographics
NPI:1396874780
Name:VACCARIELLI, LISA ANN (BS,LPN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:VACCARIELLI
Suffix:
Gender:F
Credentials:BS,LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 CENTRAL AVE APT 618
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10606-1544
Mailing Address - Country:US
Mailing Address - Phone:914-557-4809
Mailing Address - Fax:
Practice Address - Street 1:505 CENTRAL AVE APT 618
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10606-1544
Practice Address - Country:US
Practice Address - Phone:914-557-4809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01804879164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01804879Medicaid