=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235837030
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSSELL JOSHUA ROCHA DNP, APRN, FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2023
-----------------------------------------------------
Last Update Date | 10/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4600 MILITARY TRL STE 115
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33458-4811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-776-5252
-----------------------------------------------------
Fax | 561-776-5255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3098 ANGLER DR
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33445-2383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-703-0311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | APRN11024806
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------