Provider Demographics
NPI:1952414013
Name:VACCAREZZA, TERRI (NP)
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:
Last Name:VACCAREZZA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 W VINE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3731
Mailing Address - Country:US
Mailing Address - Phone:209-333-3121
Mailing Address - Fax:209-333-3008
Practice Address - Street 1:2415 W VINE ST STE 100
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3731
Practice Address - Country:US
Practice Address - Phone:209-333-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN271511363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics