Provider Demographics
NPI:1558822791
Name:VASQUEZ, KATHLEEN IDELLA-ROBICHAUD (APRN, AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:IDELLA-ROBICHAUD
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:APRN, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9662
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72033-9662
Mailing Address - Country:US
Mailing Address - Phone:501-852-1363
Mailing Address - Fax:501-852-1364
Practice Address - Street 1:2200 ADA AVE STE 201
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-4984
Practice Address - Country:US
Practice Address - Phone:501-852-1360
Practice Address - Fax:501-552-5316
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARA006157363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology