Provider Demographics
NPI:1821805748
Name:PUEBLA VAZQUEZ, YAAILEN
Entity type:Individual
Prefix:
First Name:YAAILEN
Middle Name:
Last Name:PUEBLA VAZQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:YAAILEN
Other - Middle Name:
Other - Last Name:PUEBLA VAZQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:308 FLEMING AVE
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3312
Mailing Address - Country:US
Mailing Address - Phone:561-603-9602
Mailing Address - Fax:
Practice Address - Street 1:308 FLEMING AVE
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-3312
Practice Address - Country:US
Practice Address - Phone:561-603-9602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-379675106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician