Provider Demographics
NPI:1912908484
Name:VITACCO, KIM ANN (NP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ANN
Last Name:VITACCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:KIM A VITACCO ANP-C
Mailing Address - Street 2:2 SHELTER HARBOR COURT
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2202
Mailing Address - Country:US
Mailing Address - Phone:631-886-1668
Mailing Address - Fax:631-886-1909
Practice Address - Street 1:KIM A VITACCO ANP-C
Practice Address - Street 2:2 SHELTER HARBOR COURT
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2202
Practice Address - Country:US
Practice Address - Phone:631-886-1668
Practice Address - Fax:631-886-1909
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2022-07-18
Deactivation Date:2022-04-28
Deactivation Code:
Reactivation Date:2022-06-14
Provider Licenses
StateLicense IDTaxonomies
NYF303866363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health