Provider Demographics
NPI:1508647967
Name:ROQUE, MARIE CELINE
Entity Type:Individual
Prefix:
First Name:MARIE CELINE
Middle Name:
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 1:7777 N INGRAM AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-6281
Mailing Address - Country:US
Mailing Address - Phone:559-472-7546
Mailing Address - Fax:
Practice Address - Street 1:7777 N INGRAM AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-6281
Practice Address - Country:US
Practice Address - Phone:559-472-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95025085363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner