Healthcare Provider Details

I. General information

NPI: 1194804815
Provider Name (Legal Business Name): NICHOLE A ROSA CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICHOLE A MACCONNELL

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 CHURCH ST
NEW MILFORD PA
18834-6603
US

IV. Provider business mailing address

433 CHURCH ST P.O. BOX 602
NEW MILFORD PA
18834-6603
US

V. Phone/Fax

Practice location:
  • Phone: 570-465-4500
  • Fax: 570-465-4501
Mailing address:
  • Phone: 570-465-4500
  • Fax: 570-465-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number334797
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP009050
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: