Provider Demographics
NPI:1871753566
Name:ROSE, COLLEEN (NP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0221
Mailing Address - Country:US
Mailing Address - Phone:909-580-6210
Mailing Address - Fax:909-580-1363
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:DEPT. GENERAL SURGERY MOD#3
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-6210
Practice Address - Fax:909-580-1363
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP 18595363L00000X
CARN 577240163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse