Provider Demographics
NPI:1003561747
Name:KELLY-VASQUEZ, GINA A (DNP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:A
Last Name:KELLY-VASQUEZ
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13553 AQUILINE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-3006
Mailing Address - Country:US
Mailing Address - Phone:904-412-1069
Mailing Address - Fax:
Practice Address - Street 1:1 UNF DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2645
Practice Address - Country:US
Practice Address - Phone:904-620-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11018073363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily