Healthcare Provider Details

I. General information

NPI: 1215088232
Provider Name (Legal Business Name): TETLA M ROQUES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 E 23RD ST
NEW YORK NY
10010-4516
US

IV. Provider business mailing address

3315 HONE AVE
BRONX NY
10469-3709
US

V. Phone/Fax

Practice location:
  • Phone: 212-677-7400
  • Fax:
Mailing address:
  • Phone: 718-515-5560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number296438-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: