Healthcare Provider Details

I. General information

NPI: 1477050672
Provider Name (Legal Business Name): CARRI ROSE PROM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 N ROBERTSON BLVD STE 106A
BEVERLY HILLS CA
90211-1767
US

IV. Provider business mailing address

9663 SANTA MONICA BLVD # 1151
BEVERLY HILLS CA
90210-4303
US

V. Phone/Fax

Practice location:
  • Phone: 818-922-2244
  • Fax:
Mailing address:
  • Phone: 818-922-2244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95009386
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number196026-30
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number849992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: