Provider Demographics
NPI:1255973434
Name:VELAZQUEZ, ERNESTO (APRN)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:VELAZQUEZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5564 E GRANT ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-1666
Mailing Address - Country:US
Mailing Address - Phone:321-235-6230
Mailing Address - Fax:321-235-6246
Practice Address - Street 1:865 BUENAVENTURA BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-8125
Practice Address - Country:US
Practice Address - Phone:321-235-6230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11004384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily