Provider Demographics
NPI:1962773028
Name:CONCEPCION VAZQUEZ, YENMA (MA 61848)
Entity type:Individual
Prefix:
First Name:YENMA
Middle Name:
Last Name:CONCEPCION VAZQUEZ
Suffix:
Gender:F
Credentials:MA 61848
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4233 BELLASOL CIR
Mailing Address - Street 2:APT 1811
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-7372
Mailing Address - Country:US
Mailing Address - Phone:239-244-4851
Mailing Address - Fax:
Practice Address - Street 1:4048 EVANS AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9322
Practice Address - Country:US
Practice Address - Phone:239-931-4640
Practice Address - Fax:239-931-4650
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-21
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA61848225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist