Provider Demographics
NPI:1073182937
Name:LEILUA, ROSHELLE MARIE (HIS)
Entity Type:Individual
Prefix:
First Name:ROSHELLE
Middle Name:MARIE
Last Name:LEILUA
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1468 W HUNTERS VIEW CT
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-6160
Mailing Address - Country:US
Mailing Address - Phone:801-495-4800
Mailing Address - Fax:
Practice Address - Street 1:4063 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7302
Practice Address - Country:US
Practice Address - Phone:801-495-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7984062-4601237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist