Provider Demographics
NPI:1619246006
Name:MORALES, OLIVIA VASQUEZ (NP-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:VASQUEZ
Last Name:MORALES
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:GAERLAN
Other - Last Name:VASQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:18077 OUTER HWY 18
Mailing Address - Street 2:SUITE 100
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2197
Mailing Address - Country:US
Mailing Address - Phone:760-946-8169
Mailing Address - Fax:
Practice Address - Street 1:18077 OUTER HWY 18
Practice Address - Street 2:SUITE 100
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2197
Practice Address - Country:US
Practice Address - Phone:760-946-8169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2017-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 21123363LF0000X
CA21123363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFFECTIVE 8/4/15Medicaid
CADU4034-P01528407OtherRAILROAD MEDICARE
CADU5182-P01528202OtherRAILROAD MEDICARE
CADU4034-P01528407OtherRAILROAD MEDICARE
CAEFFECTIVE 8/4/15Medicaid