Provider Demographics
NPI:1376566729
Name:VACCHELLI, KATHLEEN A (ARNP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:A
Last Name:VACCHELLI
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 LEANNI WAY UNIT B3
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-4754
Mailing Address - Country:US
Mailing Address - Phone:386-446-5494
Mailing Address - Fax:386-447-1357
Practice Address - Street 1:50 LEANNI WAY UNIT B3
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-4754
Practice Address - Country:US
Practice Address - Phone:386-446-5494
Practice Address - Fax:386-447-1357
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3368292363LP0808X
FLFL3368292363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300849501Medicaid
FL300849501Medicaid
FLE3126YMedicare PIN