Healthcare Provider Details

I. General information

NPI: 1376540039
Provider Name (Legal Business Name): ROSANNE GEPHART CNM, NP, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3630 ENTERPRISE ST
SAN DIEGO CA
92110-3212
US

IV. Provider business mailing address

5263 BEAUMONT WAY
SANTA ROSA CA
95409-2861
US

V. Phone/Fax

Practice location:
  • Phone: 619-299-0840
  • Fax: 619-291-5098
Mailing address:
  • Phone: 707-538-4781
  • Fax: 707-539-0686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberNMW744
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberNMW744
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: