Healthcare Provider Details

I. General information

NPI: 1376177105
Provider Name (Legal Business Name): ANNMARIE VIVIAN DE LA ROSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2586 BUTHMANN AVE
TRACY CA
95376-2165
US

IV. Provider business mailing address

25452 W FRAKTUR RD
BUCKEYE AZ
85326-6946
US

V. Phone/Fax

Practice location:
  • Phone: 209-832-2273
  • Fax:
Mailing address:
  • Phone: 915-226-8899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number28909
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: