Provider Demographics
NPI:1558931188
Name:VACINEK, KRISTEN NICOLE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:NICOLE
Last Name:VACINEK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 MANTLE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-5652
Mailing Address - Country:US
Mailing Address - Phone:404-394-9755
Mailing Address - Fax:
Practice Address - Street 1:6335 HOSPITAL PKWY STE 304
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-5712
Practice Address - Country:US
Practice Address - Phone:404-778-8311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-27
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN256792363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner