Provider Demographics
NPI:1841814399
Name:VASQUEZ, SKYLER G
Entity type:Individual
Prefix:
First Name:SKYLER
Middle Name:G
Last Name:VASQUEZ
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 1:203 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLE RIVE
Mailing Address - State:IL
Mailing Address - Zip Code:62810-1252
Mailing Address - Country:US
Mailing Address - Phone:618-214-2241
Mailing Address - Fax:
Practice Address - Street 1:405 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLE RIVE
Practice Address - State:IL
Practice Address - Zip Code:62810-1228
Practice Address - Country:US
Practice Address - Phone:618-316-1626
Practice Address - Fax:618-756-2566
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3747A0650XOtherVA