Provider Demographics
NPI:1124181151
Name:ROSE, BETH ANN (NP)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:ANN
Last Name:ROSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:ANN
Other - Last Name:SHERIDAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4957 OAKTON ST
Mailing Address - Street 2:STE 237
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2903
Mailing Address - Country:US
Mailing Address - Phone:773-543-6479
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:UH 1115-A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-944-7490
Practice Address - Fax:317-944-5994
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28136599A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner