Provider Demographics
NPI:1114108578
Name:ROMAN, KATHERINE (NURSE PRACTICIONER)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:NURSE PRACTICIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91275 66TH AVE
Mailing Address - Street 2:500
Mailing Address - City:MECCA
Mailing Address - State:CA
Mailing Address - Zip Code:92254-5564
Mailing Address - Country:US
Mailing Address - Phone:760-396-1249
Mailing Address - Fax:760-396-1253
Practice Address - Street 1:91275 66TH STREET
Practice Address - Street 2:500
Practice Address - City:MECCA
Practice Address - State:CA
Practice Address - Zip Code:92254
Practice Address - Country:US
Practice Address - Phone:760-396-1249
Practice Address - Fax:760-572-2255
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6013363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology