Healthcare Provider Details

I. General information

NPI: 1881506681
Provider Name (Legal Business Name): LYA VAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S ORCHARD ST
BOISE ID
83705-1966
US

IV. Provider business mailing address

9114 W CORY LN APT 101
BOISE ID
83704-6953
US

V. Phone/Fax

Practice location:
  • Phone: 208-495-5639
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberZH486645A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: