Provider Demographics
NPI:1093288383
Name:VASQUEZ, KRYSTABEL
Entity Type:Individual
Prefix:
First Name:KRYSTABEL
Middle Name:
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 GARNER FIELD RD
Mailing Address - Street 2:
Mailing Address - City:UVALDE
Mailing Address - State:TX
Mailing Address - Zip Code:78801-6209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1815 GARNER FIELD RD
Practice Address - Street 2:
Practice Address - City:UVALDE
Practice Address - State:TX
Practice Address - Zip Code:78801-6209
Practice Address - Country:US
Practice Address - Phone:830-591-1822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33647390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX390200000Medicaid