Healthcare Provider Details

I. General information

NPI: 1275445272
Provider Name (Legal Business Name): TESSA RAE ROSE LE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 MARKET AVE
COOS BAY OR
97420-2335
US

IV. Provider business mailing address

164 MARKET AVE
COOS BAY OR
97420-2335
US

V. Phone/Fax

Practice location:
  • Phone: 541-404-2441
  • Fax:
Mailing address:
  • Phone: 541-404-2441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberBAP-E-10159328
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: