Provider Demographics
NPI:1134594260
Name:BLANCHE-VEGA, IRAIDA
Entity type:Individual
Prefix:
First Name:IRAIDA
Middle Name:
Last Name:BLANCHE-VEGA
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 1:3837 SW 99TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-3907
Mailing Address - Country:US
Mailing Address - Phone:305-552-1717
Mailing Address - Fax:305-552-1782
Practice Address - Street 1:3837 SW 99TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-3907
Practice Address - Country:US
Practice Address - Phone:305-552-1717
Practice Address - Fax:305-552-1782
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2209322363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner