1689658031 NPI number — MRS. STACY RUTH ROSE CRNP

Table of content: MRS. STACY RUTH ROSE CRNP (NPI 1689658031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689658031 NPI number — MRS. STACY RUTH ROSE CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSE
Provider First Name:
STACY
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689658031
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7590 AUBURN ROAD, SUITE 014
Provider Second Line Business Mailing Address:
ATTN: MED STAFF
Provider Business Mailing Address City Name:
CONCORD TWP
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44077-9176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-354-1899
Provider Business Mailing Address Fax Number:
440-354-1845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4176 STATE ROUTE 306
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLOUGHBY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44094-9203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-918-4630
Provider Business Practice Location Address Fax Number:
440-918-4620
Provider Enumeration Date:
11/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , with the licence number:  COA.06089-NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2203627 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: H020110 . This is a "MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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