Provider Demographics
NPI:1588094445
Name:ANDERSON, ROCHELLE
Entity type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ROCHELLE
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3118 W T RYAN LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-5216
Mailing Address - Country:US
Mailing Address - Phone:602-621-6337
Mailing Address - Fax:602-601-7727
Practice Address - Street 1:3118 W T RYAN LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-5216
Practice Address - Country:US
Practice Address - Phone:602-621-6337
Practice Address - Fax:602-601-7727
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL9669H171W00000X
AZAL10582F310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ82-2200444OtherIRS