Healthcare Provider Details

I. General information

NPI: 1801442470
Provider Name (Legal Business Name): JESSICA DENISSE VAZQUEZ DNP, CRNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2019
Last Update Date: 10/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 W GIRARD AVE
PHILADELPHIA PA
19123
US

IV. Provider business mailing address

6528 MARSDEN ST
PHILADELPHIA PA
19135-2709
US

V. Phone/Fax

Practice location:
  • Phone: 215-440-9547
  • Fax:
Mailing address:
  • Phone: 267-997-9853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP-020660
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: