Healthcare Provider Details

I. General information

NPI: 1922514330
Provider Name (Legal Business Name): EVANGELINA M. ROQUE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2017
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6-20 PLAZA RD
FAIR LAWN NJ
07410-3113
US

IV. Provider business mailing address

6-20 PLAZA RD
FAIR LAWN NJ
07410-3113
US

V. Phone/Fax

Practice location:
  • Phone: 201-797-2003
  • Fax: 201-797-7003
Mailing address:
  • Phone: 201-797-2003
  • Fax: 201-797-7003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00788600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ00788600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: