Provider Demographics
NPI:1720750540
Name:ALFONSO VEGA, YAZMIN
Entity Type:Individual
Prefix:
First Name:YAZMIN
Middle Name:
Last Name:ALFONSO 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 1:6250 HAZELTINE NATIONAL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32822-5102
Mailing Address - Country:US
Mailing Address - Phone:407-237-9955
Mailing Address - Fax:833-792-1182
Practice Address - Street 1:2700 LOGANDALE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-4722
Practice Address - Country:US
Practice Address - Phone:786-559-4487
Practice Address - Fax:833-792-1182
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111598800Medicaid