Provider Demographics
NPI:1417726126
Name:PUENTE ROCA, IVIAN (AGNP-C)
Entity Type:Individual
Prefix:
First Name:IVIAN
Middle Name:
Last Name:PUENTE ROCA
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4633 BAYSHORE DR APT M2
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34112-6574
Mailing Address - Country:US
Mailing Address - Phone:503-421-7276
Mailing Address - Fax:
Practice Address - Street 1:4633 BAYSHORE DR APT M2
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-6574
Practice Address - Country:US
Practice Address - Phone:503-421-7276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAG12230019363LC1500X, 363LP2300X, 363LF0000X, 363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology