Provider Demographics
NPI:1043220155
Name:VELAZQUEZ, SANDRA J (PEDIATRIC NP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:J
Last Name:VELAZQUEZ
Suffix:
Gender:F
Credentials:PEDIATRIC NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 QUEEN ST
Mailing Address - Street 2:MEDICAL
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7700
Mailing Address - Fax:508-860-7990
Practice Address - Street 1:26 QUEEN ST
Practice Address - Street 2:MEDICAL
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2473
Practice Address - Country:US
Practice Address - Phone:508-860-7700
Practice Address - Fax:508-860-7990
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA175591363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0029009OtherNHP
MA1300709OtherCMSP
MA47954OtherFALLON SELECT
MAY10141OtherBCBS-GROUP
MA1300709OtherCMSP-GROUP
MANP1925OtherBCBS
MA1300709Medicaid
MA1300709OtherCMSP
MAY10141OtherBCBS-GROUP
MA1300709Medicaid