Healthcare Provider Details

I. General information

NPI: 1639320120
Provider Name (Legal Business Name): CATHERINE ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2008
Last Update Date: 10/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 PAUL MILLER LN NW
BEMIDJI MN
56601-5891
US

IV. Provider business mailing address

311 PAUL MILLER LN NW
BEMIDJI MN
56601-5891
US

V. Phone/Fax

Practice location:
  • Phone: 218-755-9397
  • Fax: 218-326-4714
Mailing address:
  • Phone: 218-755-9397
  • Fax: 218-326-4714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number1038060-1-AFC
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: