Provider Demographics
NPI:1659787661
Name:MEDINA VAZQUEZ, AMNERIS
Entity Type:Individual
Prefix:MRS
First Name:AMNERIS
Middle Name:
Last Name:MEDINA 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:PO BOX 591
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-0591
Mailing Address - Country:US
Mailing Address - Phone:939-630-7208
Mailing Address - Fax:
Practice Address - Street 1:CARR 111 KM 7.1
Practice Address - Street 2:
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676
Practice Address - Country:US
Practice Address - Phone:939-630-7208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6672103T00000X
PR4391701390200000X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRFM1213183-02OtherFIRST MEDICAL