Provider Demographics
NPI:1538869789
Name:VAZQUEZ CLARK, SHAQUILLA (DNP MSN CRNP FNP-BC)
Entity type:Individual
Prefix:DR
First Name:SHAQUILLA
Middle Name:
Last Name:VAZQUEZ CLARK
Suffix:
Gender:F
Credentials:DNP MSN CRNP FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:11166 FAIRFAX BLVD
Mailing Address - Street 2:STE 500 #1293
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2307
Mailing Address - Country:US
Mailing Address - Phone:703-270-1010
Mailing Address - Fax:703-991-7440
Practice Address - Street 1:11166 FAIRFAX BLVD
Practice Address - Street 2:STE 500 #1293
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030
Practice Address - Country:US
Practice Address - Phone:703-270-1010
Practice Address - Fax:410-220-8162
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX1178967363LF0000X
KY4027887363LF0000X
OHAPRN.CNP.0036121363LF0000X
VA0024189531363LF0000X
MDR193829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily