Healthcare Provider Details

I. General information

NPI: 1013491018
Provider Name (Legal Business Name): ALLISON ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2018
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 HAMMOND DR NE STE 1500
ATLANTA GA
30346-1537
US

IV. Provider business mailing address

212 MIRALUNA DR
SAN BRUNO CA
94066-1765
US

V. Phone/Fax

Practice location:
  • Phone: 855-485-8732
  • Fax:
Mailing address:
  • Phone: 916-749-5031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number728611
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: