Healthcare Provider Details

I. General information

NPI: 1881733111
Provider Name (Legal Business Name): ROSETTA LAKES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S COURT ST
MANCHESTER KY
40962-1295
US

IV. Provider business mailing address

PO BOX 158 MANCHESTER SQUARE SHOPPING CTR. ROOM 212
MANCHESTER KY
40962-0158
US

V. Phone/Fax

Practice location:
  • Phone: 606-598-2425
  • Fax: 606-598-4448
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1037165
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: