Provider Demographics
NPI:1275048605
Name:VASQUEZ, KYLEE A
Entity Type:Individual
Prefix:
First Name:KYLEE
Middle Name:A
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KYLEE
Other - Middle Name:A
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:25212 US HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:OH
Mailing Address - Zip Code:43521-9511
Mailing Address - Country:US
Mailing Address - Phone:419-237-3103
Mailing Address - Fax:419-237-4044
Practice Address - Street 1:25212 US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:FAYETTE
Practice Address - State:OH
Practice Address - Zip Code:43521-9511
Practice Address - Country:US
Practice Address - Phone:419-237-3103
Practice Address - Fax:419-237-4044
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCDCA.140402OtherLICENSE