Provider Demographics
NPI:1811353295
Name:ROQUEMORE, STACY (MSN)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:ROQUEMORE
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-1773
Mailing Address - Country:US
Mailing Address - Phone:505-599-8880
Mailing Address - Fax:505-599-8891
Practice Address - Street 1:5700 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-1773
Practice Address - Country:US
Practice Address - Phone:505-599-8880
Practice Address - Fax:505-599-8891
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR52752163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool