Provider Demographics
NPI:1700206976
Name:VACA, ELLEN LOUISE
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:LOUISE
Last Name:VACA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 ROCKLAND PL
Mailing Address - Street 2:UNIT 20
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011-1944
Mailing Address - Country:US
Mailing Address - Phone:818-691-6813
Mailing Address - Fax:
Practice Address - Street 1:4455 ROCKLAND PL
Practice Address - Street 2:UNIT 20
Practice Address - City:LA CANADA
Practice Address - State:CA
Practice Address - Zip Code:91011-1944
Practice Address - Country:US
Practice Address - Phone:818-691-6813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program