Basic Information
| Provider Information | |||||||||
| NPI: | 1598120909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VEGA | ||||||||
| FirstName: | IDAMARIS | ||||||||
| MiddleName: | |||||||||
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| Credential: | B. A. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 140 HIGH ST STE 230 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011051435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4138853864 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 511 E COLUMBUS AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011052506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4138278959 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2015 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/18/2020 | ||||||||
| NPIReactivationDate: | 11/20/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.