Healthcare Provider Details

I. General information

NPI: 1093191348
Provider Name (Legal Business Name): MARY ROSE VICENS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY ROSE BUGBEE NP

II. Dates (important events)

Enumeration Date: 08/09/2015
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-4543
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 704
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-5863
  • Fax: 585-273-1051
Mailing address:
  • Phone: 585-275-5863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number345040
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: