Provider Demographics
NPI:1285234799
Name:FUENTES VELASQUEZ, GEORGINA (NP)
Entity type:Individual
Prefix:
First Name:GEORGINA
Middle Name:
Last Name:FUENTES VELASQUEZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N SUMMIT ST FL 15
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-2615
Mailing Address - Country:US
Mailing Address - Phone:800-427-1902
Mailing Address - Fax:
Practice Address - Street 1:12101 WOODCREST EXECUTIVE DR STE 102
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-5047
Practice Address - Country:US
Practice Address - Phone:800-427-1902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020026943363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily