Provider Demographics
NPI:1144765066
Name:ROSE, TRACEY MARIA (MSN, FNP, RN-BC)
Entity Type:Individual
Prefix:MS
First Name:TRACEY
Middle Name:MARIA
Last Name:ROSE
Suffix:
Gender:F
Credentials:MSN, FNP, RN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25961 148TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2901
Mailing Address - Country:US
Mailing Address - Phone:718-978-5752
Mailing Address - Fax:
Practice Address - Street 1:25961 148TH AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-2901
Practice Address - Country:US
Practice Address - Phone:718-978-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-01
Last Update Date:2017-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33 340953363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily