Healthcare Provider Details

I. General information

NPI: 1093440828
Provider Name (Legal Business Name): JOANNA LIZETH VAZQUEZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2022
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 W ATEN RD STE 2
IMPERIAL CA
92251-9805
US

IV. Provider business mailing address

PO BOX 432
HEBER CA
92249-0432
US

V. Phone/Fax

Practice location:
  • Phone: 760-355-7730
  • Fax: 760-355-7731
Mailing address:
  • Phone: 760-554-9318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95021057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: