Provider Demographics
NPI:1720079957
Name:MORTON, ROXANNA
Entity Type:Individual
Prefix:
First Name:ROXANNA
Middle Name:
Last Name:MORTON
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 1:2831 LADBROOK WAY
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-5068
Mailing Address - Country:US
Mailing Address - Phone:805-495-6959
Mailing Address - Fax:
Practice Address - Street 1:29525 CANWOOD ST
Practice Address - Street 2:STE 111
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4233
Practice Address - Country:US
Practice Address - Phone:818-706-8133
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN525069363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics