Healthcare Provider Details

I. General information

NPI: 1689150625
Provider Name (Legal Business Name): ANJELICA VASQUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 MADISON ST
SYRACUSE NY
13210-2338
US

IV. Provider business mailing address

6321 NEW UTRECHT AVE
BROOKLYN NY
11219-5425
US

V. Phone/Fax

Practice location:
  • Phone: 315-426-3600
  • Fax:
Mailing address:
  • Phone: 212-687-7464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number724669
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: