Provider Demographics
NPI:1275665002
Name:VACCA, SUSAN H (PNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:VACCA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S BROADWAY APT 1D
Mailing Address - Street 2:
Mailing Address - City:TARRYTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10591-5308
Mailing Address - Country:US
Mailing Address - Phone:914-332-0618
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-5000
Practice Address - Fax:212-305-7400
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF380764363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics