Provider Demographics
NPI:1780186148
Name:VACCARO, ELIZABETH (APN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:VACCARO
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 STONEGATE RD
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5969
Mailing Address - Country:US
Mailing Address - Phone:847-363-0041
Mailing Address - Fax:
Practice Address - Street 1:550 W FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:IL
Practice Address - Zip Code:60093-1202
Practice Address - Country:US
Practice Address - Phone:847-386-7744
Practice Address - Fax:478-810-0838
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017066363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209017066OtherSTATE LICENSE