Healthcare Provider Details

I. General information

NPI: 1417726126
Provider Name (Legal Business Name): IVIAN PUENTE ROCA AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25511 BUDDE RD STE 3901
SPRING TX
77380-4087
US

IV. Provider business mailing address

1725 CRESCENT PLAZA DR APT 1178
HOUSTON TX
77077-2481
US

V. Phone/Fax

Practice location:
  • Phone: 281-466-4644
  • Fax:
Mailing address:
  • Phone: 503-421-7276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAG12230019
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAG12230019
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAG12230019
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1198883
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1198883
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number1198883
License Number StateTX
# 7
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAG12230019
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: