Healthcare Provider Details

I. General information

NPI: 1164961983
Provider Name (Legal Business Name): ASHLIE DANIELLE VASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASHLIE DANIELLE MENA

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 06/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 MERCANTIL AVE
ANTHONY NM
88021
US

IV. Provider business mailing address

PO DRAWER70 MEDICAID DEPT
ANTHONY NM
88021
US

V. Phone/Fax

Practice location:
  • Phone: 575-874-3592
  • Fax:
Mailing address:
  • Phone: 575-882-6101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberC-6123
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number114377
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: