Healthcare Provider Details

I. General information

NPI: 1689509671
Provider Name (Legal Business Name): KIMBERLY SUE VAZQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2026
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6331 CARMEL RD STE 102
CHARLOTTE NC
28226-8286
US

IV. Provider business mailing address

1315 EAST BLVD STE 280
CHARLOTTE NC
28203-5793
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-2354
  • Fax:
Mailing address:
  • Phone: 704-384-1866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5024447
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: