Provider Demographics
NPI:1518242767
Name:VAZQUEZ, ANTOINETTE SHAREE'
Entity Type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:SHAREE'
Last Name: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 1:1601 JOHNS LAKE RD APT 435
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-6683
Mailing Address - Country:US
Mailing Address - Phone:352-497-8713
Mailing Address - Fax:
Practice Address - Street 1:1601 JOHNS LAKE RD APT 435
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6683
Practice Address - Country:US
Practice Address - Phone:352-497-8713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2322332372600000X
FL232332376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003280500Medicaid