Provider Demographics
NPI:1508849449
Name:VELASQUEZ, MARY LOUSIE (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUSIE
Last Name:VELASQUEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 S. SULLIVAN AVE.
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205
Mailing Address - Country:US
Mailing Address - Phone:209-518-1759
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817
Practice Address - Country:US
Practice Address - Phone:916-734-5538
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF15176363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care