Healthcare Provider Details

I. General information

NPI: 1174459408
Provider Name (Legal Business Name): MABEL GRACE ROSE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2209 JOHN R WOODEN DR
MARTINSVILLE IN
46151-1840
US

IV. Provider business mailing address

540 S LINCOLN ST
MARTINSVILLE IN
46151-2213
US

V. Phone/Fax

Practice location:
  • Phone: 765-342-0539
  • Fax:
Mailing address:
  • Phone: 765-342-0539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number28289397C
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number28289397A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: