Provider Demographics
NPI:1831829464
Name:ROQUENA, FABIOLA
Entity type:Individual
Prefix:
First Name:FABIOLA
Middle Name:
Last Name:ROQUENA
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 1:4500 N TROY ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-4523
Mailing Address - Country:US
Mailing Address - Phone:773-320-0839
Mailing Address - Fax:
Practice Address - Street 1:4500 N TROY ST APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-4523
Practice Address - Country:US
Practice Address - Phone:773-320-0839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
227.002494225700000X
IL227002494225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist