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General NPI Number Information
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NPI Number | 1811865587
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Entity Type | Individual
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Provider Name | TATUM NICOLE ROSE
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Gender | Female
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Dates
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Enumeration Date | 10/25/2025
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Last Update Date | 10/25/2025
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Provider Practice Location Address
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Address Line | 615 N MICHIGAN ST
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City | SOUTH BEND
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State | IN
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Zip | 46601-1033
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Country | US
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Telephone | 574-647-7459
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Fax |
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Provider Business Mailing Address
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Address Line | 1319 EMERALD DR
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City | NILES
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State | MI
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Zip | 49120-4524
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WE0003X
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Taxonomy Name | Emergency Registered Nurse
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License Number | 28254591A
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License Number State | IN
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