Provider Demographics
NPI:1346008075
Name:ROQUE, KRISTINE DOMINGO
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:DOMINGO
Last Name:ROQUE
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 1:33018 CATTLE DR
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:CA
Mailing Address - Zip Code:92596-2264
Mailing Address - Country:US
Mailing Address - Phone:619-944-7156
Mailing Address - Fax:
Practice Address - Street 1:33018 CATTLE DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:CA
Practice Address - Zip Code:92596-2264
Practice Address - Country:US
Practice Address - Phone:619-944-7156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029290363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily