Provider Demographics
NPI:1841880077
Name:TALAVERA, ROXANA M
Entity type:Individual
Prefix:
First Name:ROXANA
Middle Name:M
Last Name:TALAVERA
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:PO BOX 1290
Mailing Address - Street 2:
Mailing Address - City:HATILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00659-1290
Mailing Address - Country:US
Mailing Address - Phone:787-402-4500
Mailing Address - Fax:
Practice Address - Street 1:BUZON 94 CARR 2 KM 88.3
Practice Address - Street 2:
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659
Practice Address - Country:US
Practice Address - Phone:787-402-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4347Medicaid