Healthcare Provider Details

I. General information

NPI: 1134856412
Provider Name (Legal Business Name): KARINA QUINTO VAZQUEZ FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2022
Last Update Date: 08/05/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2718 N PROSPECT AVE
CHAMPAIGN IL
61822-1298
US

IV. Provider business mailing address

1006 CAMBRIDGE DR
RANTOUL IL
61866-1202
US

V. Phone/Fax

Practice location:
  • Phone: 217-337-3852
  • Fax:
Mailing address:
  • Phone: 217-390-1479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209025089
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: