Healthcare Provider Details

I. General information

NPI: 1720978661
Provider Name (Legal Business Name): SOUNTHARY ROQUES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2025
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N D ST # 320
SAN BERNARDINO CA
92401-1545
US

IV. Provider business mailing address

14783 GREEN LAWN DR
MORENO VALLEY CA
92555-5744
US

V. Phone/Fax

Practice location:
  • Phone: 909-893-2782
  • Fax:
Mailing address:
  • Phone: 909-809-1160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number95085621
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number95085621
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number95085621
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number95085621
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: