Healthcare Provider Details

I. General information

NPI: 1285966507
Provider Name (Legal Business Name): SHANA D VAZQUEZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 11/22/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21227 TORCH ST
FT BLISS TX
79918
US

IV. Provider business mailing address

13677 GLEN VISTA LN
HORIZON CITY TX
79928-6082
US

V. Phone/Fax

Practice location:
  • Phone: 915-742-9232
  • Fax:
Mailing address:
  • Phone: 808-778-3901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1114997
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: