Healthcare Provider Details

I. General information

NPI: 1801852306
Provider Name (Legal Business Name): KRISTINE KAY VASQUEZ OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 S 3RD ST
WILLIAMS AZ
86046-2404
US

IV. Provider business mailing address

222 S GOLDEN MEADOW TRL
WILLIAMS AZ
86046-9625
US

V. Phone/Fax

Practice location:
  • Phone: 928-635-1477
  • Fax: 928-635-0143
Mailing address:
  • Phone: 928-635-2042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0411
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: