Provider Demographics
NPI:1518778166
Name:VAZQUEZ, GABRIELLA ROSE
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:ROSE
Last Name:VAZQUEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:393-437-4902
Mailing Address - Fax:
Practice Address - Street 1:9981 S HEALTHPARK DR STE 304
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3618
Practice Address - Country:US
Practice Address - Phone:239-343-5437
Practice Address - Fax:239-343-4197
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11031112363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL126219300Medicaid