Provider Demographics
NPI:1902428915
Name:RICHARDSON, ROXANN JEANETTE
Entity Type:Individual
Prefix:
First Name:ROXANN
Middle Name:JEANETTE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROXANN
Other - Middle Name:JEANETTE
Other - Last Name:ROHDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1075 ROBERTA LN STE 102
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431-1893
Mailing Address - Country:US
Mailing Address - Phone:775-209-7065
Mailing Address - Fax:
Practice Address - Street 1:1075 ROBERTA LN STE 102
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-1893
Practice Address - Country:US
Practice Address - Phone:775-209-7065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant