=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841000916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSELINE ETA-MANKE NDIP DNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2025
-----------------------------------------------------
Last Update Date | 01/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41800 W 11 MILE RD STE 109
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48375-1818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-660-1220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12018 GOLDENROD ST NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55448-2487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-777-2125
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 12224
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------