Healthcare Provider Details

I. General information

NPI: 1073063954
Provider Name (Legal Business Name): MRS. ROSA DEANNA PEREZ VALENZUELA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 THERESA ST
WATERTOWN WI
53094-6737
US

IV. Provider business mailing address

417 THERESA ST
WATERTOWN WI
53094-6737
US

V. Phone/Fax

Practice location:
  • Phone: 989-274-3909
  • Fax:
Mailing address:
  • Phone: 989-274-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number231387
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: