Healthcare Provider Details

I. General information

NPI: 1457176554
Provider Name (Legal Business Name): ROSE MARY B RODRIGUES AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROSE MARY B RODRIGUES AGACNP

II. Dates (important events)

Enumeration Date: 11/22/2024
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6268 AUTUMNWOOD DR
RIVERSIDE CA
92505-2296
US

IV. Provider business mailing address

6268 AUTUMNWOOD DR
RIVERSIDE CA
92505-2296
US

V. Phone/Fax

Practice location:
  • Phone: 951-901-3246
  • Fax:
Mailing address:
  • Phone: 951-901-3246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95031995
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: