Healthcare Provider Details

I. General information

NPI: 1871926204
Provider Name (Legal Business Name): KATHLEEN M ROSE NP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 11/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 WEST ST
CANANDAIGUA NY
14424-1722
US

IV. Provider business mailing address

3200 WEST ST
CANANDAIGUA NY
14424-1722
US

V. Phone/Fax

Practice location:
  • Phone: 585-905-0061
  • Fax:
Mailing address:
  • Phone: 585-905-0061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number308945
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number686821
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number308304
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: