Healthcare Provider Details

I. General information

NPI: 1275193450
Provider Name (Legal Business Name): MRS. TRICIA KAY ROSA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 KENMOOR AVE SE STE 100
GRAND RAPIDS MI
49546-8602
US

IV. Provider business mailing address

801 ROSEHILL RD
JACKSON MI
49202-1762
US

V. Phone/Fax

Practice location:
  • Phone: 616-272-3533
  • Fax: 616-259-4839
Mailing address:
  • Phone: 517-212-2008
  • Fax: 517-212-9023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704278243
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3017093
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number4704278243
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: