Provider Demographics
NPI:1447459961
Name:VASQUEZ VELASQUEZ, JEANETTE (LPN)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:
Last Name:VASQUEZ VELASQUEZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:JEANETTE
Other - Middle Name:
Other - Last Name:KIRCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:6 BELLAIRE AVE
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-3217
Mailing Address - Country:US
Mailing Address - Phone:516-946-1527
Mailing Address - Fax:
Practice Address - Street 1:6 BELLAIRE AVE
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-3217
Practice Address - Country:US
Practice Address - Phone:516-946-1527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-14
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213407-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02197900Medicaid
NY213407-1OtherNYS LICENSE