Provider Demographics
NPI:1871732883
Name:ROSE, ANITA LYNN (RN)
Entity type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:LYNN
Last Name:ROSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:410 GLENN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1200
Mailing Address - Country:US
Mailing Address - Phone:570-784-1723
Mailing Address - Fax:570-784-8512
Practice Address - Street 1:410 GLENN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1200
Practice Address - Country:US
Practice Address - Phone:570-784-1723
Practice Address - Fax:570-784-8512
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN503929L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1255488904OtherNPI NUMBER FOR FACILITY
PA100746682006Medicaid
PA1022487130001Medicaid