MEDICARE: DR. SUSAN S. ROSE PHD, GCNS-BC, PMHNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	200850041NP	OR
2	364SG0600X	Gerontology Clinical Nurse Specialist	200470003	OR
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP60031978	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G8878364	OTHER	WA	MEDICARE

General Provider Information

NPI Number	:	1750318788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN S. ROSE PHD, GCNS-BC, PMHNP

Provider Business Mailing Address
First Line	:	PO BOX 873473
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98687-3473
Country	:	US
Telephone Number	:	971-258-0854
Fax Number	:

Provider Business Practice Location Address
First Line	:	PO BOX 873473
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98687-3473
Country	:	US
Telephone Number	:	971-258-0854
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	05/02/2025

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