Provider Demographics
NPI:1689140774
Name:ROLDAN, BRIANA B
Entity Type:Individual
Prefix:
First Name:BRIANA
Middle Name:B
Last Name:ROLDAN
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 1:716 SALIDA SANDIA SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-7600
Mailing Address - Country:US
Mailing Address - Phone:505-450-2150
Mailing Address - Fax:
Practice Address - Street 1:2301 YALE BLVD SE BLDG F
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4228
Practice Address - Country:US
Practice Address - Phone:505-272-1221
Practice Address - Fax:505-925-4354
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
373H00000X, 171M00000X
NM225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45172871Medicaid