Provider Demographics
NPI:1790955284
Name:RENDEROS, ROXANNA IRENE
Entity Type:Individual
Prefix:
First Name:ROXANNA
Middle Name:IRENE
Last Name:RENDEROS
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 1:3851 ROSECRANS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3115
Mailing Address - Country:US
Mailing Address - Phone:619-861-2096
Mailing Address - Fax:
Practice Address - Street 1:3851 ROSECRANS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3134
Practice Address - Country:US
Practice Address - Phone:619-861-2096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program