Provider Demographics
NPI:1073619565
Name:ROSE, ANGELA M (LPN)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:M
Last Name:ROSE
Suffix:
Gender:F
Credentials:LPN
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 622
Mailing Address - Street 2:
Mailing Address - City:NEWALLA
Mailing Address - State:OK
Mailing Address - Zip Code:74857-0622
Mailing Address - Country:US
Mailing Address - Phone:405-878-4693
Mailing Address - Fax:405-878-4690
Practice Address - Street 1:2307 S GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9007
Practice Address - Country:US
Practice Address - Phone:405-878-4693
Practice Address - Fax:405-878-4690
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0050173164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse