Provider Demographics
NPI:1568681195
Name:BASQUES, ROBERTA A (LPN)
Entity type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:A
Last Name:BASQUES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3029 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-3438
Mailing Address - Country:US
Mailing Address - Phone:602-336-0061
Mailing Address - Fax:
Practice Address - Street 1:6601 N 27TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-1219
Practice Address - Country:US
Practice Address - Phone:602-336-0061
Practice Address - Fax:602-336-0249
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP006078164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse