Provider Demographics
NPI:1407580095
Name:VIGIL, DESIRAE RENEE (AP)
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:RENEE
Last Name:VIGIL
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12840 HOLLY ST UNIT 120
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80602-8289
Mailing Address - Country:US
Mailing Address - Phone:720-232-7135
Mailing Address - Fax:
Practice Address - Street 1:12840 HOLLY ST UNIT 120
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80602-8289
Practice Address - Country:US
Practice Address - Phone:720-232-7135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCOZ720555174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOZ720555OtherDORA