Healthcare Provider Details

I. General information

NPI: 1063901122
Provider Name (Legal Business Name): ROSALEE ROCHE CARROLL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 02/11/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S COMMERCIAL AVE
HIGHMORE SD
57345
US

IV. Provider business mailing address

202 ISLAND DR STE 1
FORT PIERRE SD
57532-7303
US

V. Phone/Fax

Practice location:
  • Phone: 605-852-2238
  • Fax:
Mailing address:
  • Phone: 605-223-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP001369
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: