Provider Demographics
NPI:1053073825
Name:ROSA, WHITNEY NICOLE
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:NICOLE
Last Name:ROSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10144 W LAKE PLEASANT PKWY
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-9716
Mailing Address - Country:US
Mailing Address - Phone:623-434-5748
Mailing Address - Fax:
Practice Address - Street 1:10144 W LAKE PLEASANT PKWY
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-9716
Practice Address - Country:US
Practice Address - Phone:623-434-5748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-09
Last Update Date:2021-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ179159363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care