Provider Demographics
NPI:1275041444
Name:VELAZQUEZ, PRINCESS
Entity Type:Individual
Prefix:
First Name:PRINCESS
Middle Name:
Last Name:VELAZQUEZ
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 1:160 PALM DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:TX
Mailing Address - Zip Code:75146-1942
Mailing Address - Country:US
Mailing Address - Phone:214-395-6005
Mailing Address - Fax:817-393-4934
Practice Address - Street 1:160 PALM DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:TX
Practice Address - Zip Code:75146-1942
Practice Address - Country:US
Practice Address - Phone:214-395-6005
Practice Address - Fax:817-393-4934
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX28856836Medicaid