Provider Demographics
NPI:1043054349
Name:ROSA, ANGELA (APRN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:ROSA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 S MAIN ST UNIT 701
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-4116
Mailing Address - Country:US
Mailing Address - Phone:773-701-3257
Mailing Address - Fax:
Practice Address - Street 1:656 E 11400 S STE N
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9786
Practice Address - Country:US
Practice Address - Phone:801-849-1604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-21
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13340981-4405363L00000X
UT13340981-8900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner