Healthcare Provider Details

I. General information

NPI: 1053168559
Provider Name (Legal Business Name): MARCELLA VAZQUEZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2024
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 W INTERLAKE BLVD
LAKE PLACID FL
33852-9653
US

IV. Provider business mailing address

2675 WINKLER AVE STE 200
FORT MYERS FL
33901-9328
US

V. Phone/Fax

Practice location:
  • Phone: 863-465-7010
  • Fax: 863-465-4223
Mailing address:
  • Phone: 877-856-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11028182
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11028182
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: