Provider Demographics
NPI:1801852306
Name:VASQUEZ, KRISTINE KAY (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:KAY
Last Name:VASQUEZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S GOLDEN MEADOW TRL
Mailing Address - Street 2:
Mailing Address - City:WILLIAMS
Mailing Address - State:AZ
Mailing Address - Zip Code:86046-9625
Mailing Address - Country:US
Mailing Address - Phone:928-635-2042
Mailing Address - Fax:
Practice Address - Street 1:122 S 3RD ST
Practice Address - Street 2:
Practice Address - City:WILLIAMS
Practice Address - State:AZ
Practice Address - Zip Code:86046-2404
Practice Address - Country:US
Practice Address - Phone:928-635-1477
Practice Address - Fax:928-635-0143
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0411174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0293560OtherBCBS
AZ19033560OtherWORKER'S COMP
AZ771479OtherAHCCCS
AZS21636Medicare ID - Type Unspecified