MEDICARE: LISSETT MORALES ROQUE PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	11045662	FL

General Provider Information

NPI Number	:	1457206963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISSETT MORALES ROQUE PMHNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 126900
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-1614
Country	:	US
Telephone Number	:	786-603-6109
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 126900
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33012-1614
Country	:	US
Telephone Number	:	786-603-6109
Fax Number	:

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

Provider Enumeration Date	:	03/02/2026
Last Update Date	:	03/02/2026

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