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General NPI Number Information
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NPI Number | 1972380590
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Entity Type | Individual
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Provider Name | KELLY DIAZ-VAZQUEZ APRN
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Gender | Female
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Dates
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Enumeration Date | 09/08/2023
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Last Update Date | 10/18/2023
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Provider Practice Location Address
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Address Line | 8550 NE 138TH LN BLDG 500
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City | LADY LAKE
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State | FL
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Zip | 32159-8957
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Country | US
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Telephone | 352-633-9858
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Fax |
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Provider Business Mailing Address
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Address Line | 8550 NE 138TH LN BLDG 500
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City | LADY LAKE
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State | FL
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Zip | 32159-8957
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Country | US
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Telephone | 352-333-9858
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | APRN11027606
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License Number State | FL
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