Healthcare Provider Details

I. General information

NPI: 1124574686
Provider Name (Legal Business Name): VANESSA ROLSTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 W QUAY AVE
ARTESIA NM
88210-1826
US

IV. Provider business mailing address

1106 W QUAY AVE
ARTESIA NM
88210-1826
US

V. Phone/Fax

Practice location:
  • Phone: 575-746-2777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number5923
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: