Provider Demographics
NPI:1558144030
Name:VAZQUEZ, KELLY (APN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 LAUREL OAK RD
Mailing Address - Street 2:ST. B
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4424
Mailing Address - Country:US
Mailing Address - Phone:856-566-5478
Mailing Address - Fax:856-566-9563
Practice Address - Street 1:201 LAUREL OAK RD
Practice Address - Street 2:ST. B
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4424
Practice Address - Country:US
Practice Address - Phone:856-566-5478
Practice Address - Fax:856-566-9563
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14900000363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health