Provider Demographics
NPI:1275075798
Name:COLON VAZQUEZ, KEISHLA MARIE
Entity Type:Individual
Prefix:
First Name:KEISHLA
Middle Name:MARIE
Last Name:COLON VAZQUEZ
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:CARR 780 KM 1.0
Mailing Address - Street 2:BO PALOMAS
Mailing Address - City:COMERIO
Mailing Address - State:PR
Mailing Address - Zip Code:00782
Mailing Address - Country:US
Mailing Address - Phone:193-923-1113
Mailing Address - Fax:
Practice Address - Street 1:HC 4 BOX 8402
Practice Address - Street 2:
Practice Address - City:COMERIO
Practice Address - State:PR
Practice Address - Zip Code:00782-9785
Practice Address - Country:US
Practice Address - Phone:939-273-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR11523183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician