Provider Demographics
NPI:1114403409
Name:VASQUEZ, MILDRED LOPEZ
Entity Type:Individual
Prefix:MRS
First Name:MILDRED
Middle Name:LOPEZ
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 1:12 ROWLAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:201-341-4677
Mailing Address - Fax:
Practice Address - Street 1:12 ROWLAND AVENUE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601
Practice Address - Country:US
Practice Address - Phone:201-341-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJS130018374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty