MEDICARE: TEKOA ROSE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	908286	MS
2	363LF0000X	Family Nurse Practitioner	28906	TN

General Provider Information

NPI Number	:	1508452202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEKOA ROSE NP

Provider Business Mailing Address
First Line	:	8750 WOOD THRUSH DR
Second Line	:
City	:	OLIVE BRANCH
State	:	MS
Zip	:	38654-2028
Country	:	US
Telephone Number	:	901-482-1659
Fax Number	:

Provider Business Practice Location Address
First Line	:	3206 POPLAR AVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38111-3502
Country	:	US
Telephone Number	:	901-842-3160
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2020
Last Update Date	:	04/11/2023

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Directions to “ TEKOA ROSE NP” Practice Location

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