Provider Demographics
NPI:1679817969
Name:ROMAN, CLARISSA LUZ
Entity Type:Individual
Prefix:MRS
First Name:CLARISSA
Middle Name:LUZ
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CLARISSA
Other - Middle Name:LUZ
Other - Last Name:SANTIAGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1176 HOE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-1915
Mailing Address - Country:US
Mailing Address - Phone:646-260-9836
Mailing Address - Fax:
Practice Address - Street 1:1176 HOE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-1915
Practice Address - Country:US
Practice Address - Phone:646-260-9836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312204-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse