Provider Demographics
NPI:1760053318
Name:VIVACQUA, BRIANA MARIE
Entity Type:Individual
Prefix:MS
First Name:BRIANA
Middle Name:MARIE
Last Name:VIVACQUA
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 1:32W161 CHURCHILL LN
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:IL
Mailing Address - Zip Code:60184-2353
Mailing Address - Country:US
Mailing Address - Phone:630-514-0526
Mailing Address - Fax:
Practice Address - Street 1:120 E OGDEN AVE STE 220
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3546
Practice Address - Country:US
Practice Address - Phone:630-325-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program