Provider Demographics
NPI:1174845671
Name:BALLARD, ROSA (LPN)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 COWLES ST APT 6
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5938
Mailing Address - Country:US
Mailing Address - Phone:907-374-7702
Mailing Address - Fax:
Practice Address - Street 1:3830 S CUSHMAN ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7530
Practice Address - Country:US
Practice Address - Phone:907-452-1575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK6342164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse