Basic Information
| Provider Information | |||||||||
| NPI: | 1154070282 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VACCARO | ||||||||
| FirstName: | KRISTEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 FOREST GATE CIR | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605232129 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3249 OAK PARK AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604023429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087833425 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2022 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 125.079357 | IL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 125.079357 | 01 | IL | DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION | OTHER |