Provider Demographics
NPI:1609952670
Name:VELAZQUEZ, VIRGINIA L (NP)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:L
Last Name:VELAZQUEZ
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 1:1235 N MULFORD RD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3879
Mailing Address - Country:US
Mailing Address - Phone:815-397-8400
Mailing Address - Fax:815-229-0050
Practice Address - Street 1:1235 N MULFORD RD
Practice Address - Street 2:SUITE 222
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3879
Practice Address - Country:US
Practice Address - Phone:815-397-8400
Practice Address - Fax:815-229-0050
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041263753163W00000X
IL209-006069363L00000X
IL209006069363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL820800061OtherMEDICARE PTAN (INDIVIDUAL)
IL820800OtherMEDICARE PTAN (GROUP)
IL209006069OtherLICENSE
IL820800OtherMEDICARE PTAN (GROUP)