Provider Demographics
NPI:1972380590
Name:DIAZ-VAZQUEZ, KELLY (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DIAZ-VAZQUEZ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 NE 138TH LN BLDG 500
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-8957
Mailing Address - Country:US
Mailing Address - Phone:352-333-9858
Mailing Address - Fax:
Practice Address - Street 1:8550 NE 138TH LN BLDG 500
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8957
Practice Address - Country:US
Practice Address - Phone:352-633-9858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11027606363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner