Provider Demographics
NPI:1033468855
Name:VULTAGGIO, TAWNYA NICOLE (RN)
Entity Type:Individual
Prefix:MRS
First Name:TAWNYA
Middle Name:NICOLE
Last Name:VULTAGGIO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TAWNYA
Other - Middle Name:NICOLE
Other - Last Name:FARR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:9448D FEW LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-3204
Mailing Address - Country:US
Mailing Address - Phone:480-907-9201
Mailing Address - Fax:
Practice Address - Street 1:9448D FEW LOOP
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13603-3204
Practice Address - Country:US
Practice Address - Phone:480-907-9201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY658555163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse