Basic Information
Provider Information | |||||||||
NPI: | 1306817374 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VACEK | ||||||||
FirstName: | DEBORAH | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | VACEK | ||||||||
OtherFirstName: | DEBORAH | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 34800 BOB WILSON DR | ||||||||
Address2: | NMCSD, ATTN: MEDICAL STAFF SERVICES | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921341098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195326460 | ||||||||
FaxNumber: | 6195326299 | ||||||||
Practice Location | |||||||||
Address1: | 34800 BOB WILSON DR | ||||||||
Address2: | NMCSD, ATTN: MEDICAL STAFF SERVICES | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921341098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6195326460 | ||||||||
FaxNumber: | 6195326299 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2006 | ||||||||
LastUpdateDate: | 10/22/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 289800 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.