Basic Information
| Provider Information | |||||||||
| NPI: | 1255418968 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VACCANI | ||||||||
| FirstName: | JOANNE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 624 MARKET AVE N | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447021017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3308335530 | ||||||||
| FaxNumber: | 3308336085 | ||||||||
| Practice Location | |||||||||
| Address1: | 624 MARKET AVE N | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 447021017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304934553 | ||||||||
| FaxNumber: | 3304933761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 04/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0809X | COA.02622-NS | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult | 163W00000X | NS02622 | OH | N | Nursing Service Providers | Registered Nurse | 163W00000X | 070153-1 | OH | N | Nursing Service Providers | Registered Nurse | 163WP0809X | 242355-01 | OH | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 163WP0809X | CTP02622RX | OH | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 364SP0809X | RX-02622 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 3102690 | 05 | OH | MEDICAID |