Provider Demographics
NPI:1134498652
Name:ROSE, ANGELA MYRIAH (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MYRIAH
Last Name:ROSE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 S ZINTEL WAY
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-5092
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:28900 SW VILLEBOIS DR.
Practice Address - Street 2:SUITE D
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070
Practice Address - Country:US
Practice Address - Phone:503-482-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201403549NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0289786OtherLABOR & INDUSTRIES
WA1134498652Medicaid
WA8906182Medicare PIN