Provider Demographics
NPI:1124568084
Name:FLAHERTY, ROXANNE MARIA
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:MARIA
Last Name:FLAHERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 S RIDGELEY DR APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-2668
Mailing Address - Country:US
Mailing Address - Phone:310-569-2930
Mailing Address - Fax:
Practice Address - Street 1:11400 W OLYMPIC BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1584
Practice Address - Country:US
Practice Address - Phone:323-326-6182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-26
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005415363LP0808X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health