MEDICARE: ROSELVA MENDOZA ROSETELOPEZ RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WX0003X	Inpatient Obstetric Registered Nurse	RN120451	AZ

General Provider Information

NPI Number	:	1306894605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSELVA MENDOZA ROSETELOPEZ RN

Provider Business Mailing Address
First Line	:	1901 ANZIO ST
Second Line	:
City	:	FORT IRWIN
State	:	CA
Zip	:	92310-1613
Country	:	US
Telephone Number	:	760-386-1490
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 ANZIO STREET
Second Line	:
City	:	FORT IRWIN
State	:	CA
Zip	:	92310-1613
Country	:	US
Telephone Number	:	760-386-1490
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	07/08/2007

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