Healthcare Provider Details

I. General information

NPI: 1497348254
Provider Name (Legal Business Name): JENNIFER R ROSE CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 TAYLOR AVE
SHERIDAN WY
82801-2331
US

IV. Provider business mailing address

1428 TAYLOR AVE
SHERIDAN WY
82801-2331
US

V. Phone/Fax

Practice location:
  • Phone: 307-620-2912
  • Fax: 307-464-7057
Mailing address:
  • Phone: 307-620-2912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number46645
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: