1558988220 NPI number — SUSAN MARIE ROSETTE

Table of content: SUSAN MARIE ROSETTE (NPI 1558988220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558988220 NPI number — SUSAN MARIE ROSETTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROSETTE
Provider First Name:
SUSAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1558988220
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/09/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
713 12TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TWO HARBORS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55616-1219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-969-6183
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
713 12TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWO HARBORS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55616-1219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-969-6183
Provider Business Practice Location Address Fax Number:
218-969-6183
Provider Enumeration Date:
06/29/2020

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: 225700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 372500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 372600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 376J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 376K00000X , with the licence number: 10827825 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10827825 . This is a "NURSING ASSISTANT CERTIFICATE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".