Healthcare Provider Details

I. General information

NPI: 1255295077
Provider Name (Legal Business Name): ROSE NA NANSUKUSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 MOWER ST
WORCESTER MA
01602-4132
US

IV. Provider business mailing address

45 MOWER ST
WORCESTER MA
01602-4132
US

V. Phone/Fax

Practice location:
  • Phone: 774-535-3715
  • Fax:
Mailing address:
  • Phone: 774-535-3715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLN101023
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: