Provider Demographics
NPI:1912663253
Name:VIQUEZ, VINICIO
Entity Type:Individual
Prefix:
First Name:VINICIO
Middle Name:
Last Name:VIQUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:VINICIO
Other - Middle Name:
Other - Last Name:VIQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COSMETOLOGIST
Mailing Address - Street 1:1520 23RD AVE RM 7
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2919
Mailing Address - Country:US
Mailing Address - Phone:617-694-6006
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:1520 23RD AVE RM 7
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-2919
Practice Address - Country:US
Practice Address - Phone:617-694-6006
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL1278006163WC1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWR70521AMedicaid