Provider Demographics
NPI:1265656763
Name:VAZQUEZ, IDELISSE (PT)
Entity Type:Individual
Prefix:MRS
First Name:IDELISSE
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 75 BOX 1818
Mailing Address - Street 2:
Mailing Address - City:NARANJITO
Mailing Address - State:PR
Mailing Address - Zip Code:00719-9719
Mailing Address - Country:US
Mailing Address - Phone:787-869-1462
Mailing Address - Fax:
Practice Address - Street 1:HC 75 BOX 1818
Practice Address - Street 2:
Practice Address - City:NARANJITO
Practice Address - State:PR
Practice Address - Zip Code:00719-9719
Practice Address - Country:US
Practice Address - Phone:787-869-1462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5804183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5804OtherPT