Provider Demographics
NPI:1376815217
Name:FALLICA, VINCINE ANTONIA (RN)
Entity Type:Individual
Prefix:
First Name:VINCINE
Middle Name:ANTONIA
Last Name:FALLICA
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 MAIN ST
Mailing Address - Street 2:APT 6
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-1756
Mailing Address - Country:US
Mailing Address - Phone:518-637-7582
Mailing Address - Fax:
Practice Address - Street 1:129 MAIN ST
Practice Address - Street 2:APT 6
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-1756
Practice Address - Country:US
Practice Address - Phone:518-637-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY535322-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse