Provider Demographics
NPI:1245442482
Name:PEREZ, ROXANE JULIET (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:ROXANE
Middle Name:JULIET
Last Name:PEREZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:MS
Other - First Name:ROXANE
Other - Middle Name:JULIET
Other - Last Name:DEMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 6830
Mailing Address - Street 2:CSUF STUDENT HEALTH AND COUSSELING CENTER
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92834-3069
Mailing Address - Country:US
Mailing Address - Phone:657-278-2800
Mailing Address - Fax:
Practice Address - Street 1:800 N. ST COLLEGE BLVD
Practice Address - Street 2:STUDENT HEALTH AND COUNSELING CENTER
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92834-3069
Practice Address - Country:US
Practice Address - Phone:657-278-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 16948363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABI357XMedicare PIN
CABI749YMedicare PIN
CABI749ZMedicare PIN