Provider Demographics
NPI:1063030088
Name:VASQUEZ, KRISTAL LADAWN (AGNP-C)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:LADAWN
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 S MAIN ST STE 1300
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-5513
Mailing Address - Country:US
Mailing Address - Phone:866-949-0108
Mailing Address - Fax:
Practice Address - Street 1:1831 E 71ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3922
Practice Address - Country:US
Practice Address - Phone:866-949-0108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-07
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK108337363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care