Provider Demographics
NPI:1093996449
Name:PRINCE, ROSANNE (AUD, CCC/A)
Entity Type:Individual
Prefix:
First Name:ROSANNE
Middle Name:
Last Name:PRINCE
Suffix:
Gender:F
Credentials:AUD, CCC/A
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 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-7665
Mailing Address - Fax:307-739-4940
Practice Address - Street 1:555 E BROADWAY AVE STE 229
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001
Practice Address - Country:US
Practice Address - Phone:307-739-7665
Practice Address - Fax:307-739-4940
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYA-990231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY131893400Medicaid