Healthcare Provider Details

I. General information

NPI: 1548935935
Provider Name (Legal Business Name): VICTORIA FAITH ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 MARTIN RD STE 200
FAIRFIELD CA
94534-8610
US

IV. Provider business mailing address

2420 MARTIN RD STE 200
FAIRFIELD CA
94534-8610
US

V. Phone/Fax

Practice location:
  • Phone: 916-921-0828
  • Fax:
Mailing address:
  • Phone: 707-330-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: