Healthcare Provider Details

I. General information

NPI: 1811353295
Provider Name (Legal Business Name): STACY ROQUEMORE MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2016
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 COLLEGE BLVD
FARMINGTON NM
87402-1773
US

IV. Provider business mailing address

5700 COLLEGE BLVD
FARMINGTON NM
87402-1773
US

V. Phone/Fax

Practice location:
  • Phone: 505-599-8880
  • Fax: 505-599-8891
Mailing address:
  • Phone: 505-599-8880
  • Fax: 505-599-8891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR52752
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: