Healthcare Provider Details

I. General information

NPI: 1003681727
Provider Name (Legal Business Name): ANNIE ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2023
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

1428 BONITA AVE
BERKELEY CA
94709-1909
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-4418
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95000457
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: