Healthcare Provider Details

I. General information

NPI: 1225069412
Provider Name (Legal Business Name): ROSE M ROSS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 E MILLER RD
FAIRVIEW MI
48621-8731
US

IV. Provider business mailing address

1910 E MILLER RD PO BOX 460
FAIRVIEW MI
48621-8731
US

V. Phone/Fax

Practice location:
  • Phone: 989-848-5484
  • Fax: 989-848-7139
Mailing address:
  • Phone: 989-848-5484
  • Fax: 989-848-7139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704091848
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: