Healthcare Provider Details

I. General information

NPI: 1487399366
Provider Name (Legal Business Name): YESENIA MARY MALAVE VAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2241 BRIAN AVE
SOUTH DAYTONA FL
32119-2721
US

IV. Provider business mailing address

2241 BRIAN AVE
SOUTH DAYTONA FL
32119-2721
US

V. Phone/Fax

Practice location:
  • Phone: 386-547-0554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11019521
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11019521
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: