Provider Demographics
NPI:1689379091
Name:ROLLE, CLINTINA
Entity Type:Individual
Prefix:
First Name:CLINTINA
Middle Name:
Last Name:ROLLE
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 1:8507 NW 61ST ST
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-3762
Mailing Address - Country:US
Mailing Address - Phone:754-271-3886
Mailing Address - Fax:
Practice Address - Street 1:8507 NW 61ST ST
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-3762
Practice Address - Country:US
Practice Address - Phone:754-271-3886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL239009374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide