Provider Demographics
NPI:1720860406
Name:VAZQUEZ VIDAL, VANESSA (NP)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:VAZQUEZ VIDAL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5660 N TRACY AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-2571
Mailing Address - Country:US
Mailing Address - Phone:559-307-9451
Mailing Address - Fax:
Practice Address - Street 1:121 W SIERRA ST
Practice Address - Street 2:
Practice Address - City:KINGSBURG
Practice Address - State:CA
Practice Address - Zip Code:93631-1756
Practice Address - Country:US
Practice Address - Phone:559-326-5320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027685363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health