Provider Demographics
NPI:1265806053
Name:VACCHIO-CAULLEY, NOELLE DOMINIQUE (PA-C)
Entity type:Individual
Prefix:
First Name:NOELLE
Middle Name:DOMINIQUE
Last Name:VACCHIO-CAULLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 71ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-4205
Mailing Address - Country:US
Mailing Address - Phone:541-968-6676
Mailing Address - Fax:
Practice Address - Street 1:2042 NE WILLIAMSON CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3760
Practice Address - Country:US
Practice Address - Phone:541-706-6905
Practice Address - Fax:541-706-6906
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR174942363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant