Provider Demographics
NPI:1083075220
Name:VINES, ROSA
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:VINES
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 1:900 BERT RD APT F134
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-5963
Mailing Address - Country:US
Mailing Address - Phone:912-631-0158
Mailing Address - Fax:
Practice Address - Street 1:900 BERT RD APT F134
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211
Practice Address - Country:US
Practice Address - Phone:912-631-0158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50175752376K00000X
FLCNA147782376K00000X
OH322212421103376K00000X
GACNA14178582376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide