Provider Demographics
NPI:1346757911
Name:NORIEGA, ROSA M
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:M
Last Name:NORIEGA
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 1:3876 BEVERLY AVE NE BLDG G
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1319
Mailing Address - Country:US
Mailing Address - Phone:503-361-2702
Mailing Address - Fax:
Practice Address - Street 1:3876 BEVERLY AVE NE BLDG G
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1319
Practice Address - Country:US
Practice Address - Phone:503-361-2702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OR1346757911171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty