Provider Demographics
NPI:1639498157
Name:VACCA, NANCY JULIETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:JULIETTE
Last Name:VACCA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WILFORD HALL LOOP BLDG 4554
Mailing Address - Street 2:
Mailing Address - City:JBSA LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5638
Mailing Address - Country:US
Mailing Address - Phone:210-292-5736
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP BLDG 4554
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5638
Practice Address - Country:US
Practice Address - Phone:210-292-5736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX327279102Medicaid
TX327279102Medicaid