Provider Demographics
NPI:1871882654
Name:VAZQUEZ, NIKITA
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:VAZQUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:196 ARROWHEAD DR.
Mailing Address - Street 2:STE. 6
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-8752
Mailing Address - Country:US
Mailing Address - Phone:307-789-4224
Mailing Address - Fax:307-789-4225
Practice Address - Street 1:196 ARROWHEAD DR.
Practice Address - Street 2:STE. 6
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-8752
Practice Address - Country:US
Practice Address - Phone:307-789-4224
Practice Address - Fax:307-789-4225
Is Sole Proprietor?:No
Enumeration Date:2011-04-01
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY376K00000X
172V00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No376K00000XNursing Service Related ProvidersNurse's Aide