Provider Demographics
NPI:1194201533
Name:DE LA ROSA, LORENA MARGARET
Entity Type:Individual
Prefix:
First Name:LORENA
Middle Name:MARGARET
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16503 W SUMMERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5756
Mailing Address - Country:US
Mailing Address - Phone:626-422-5227
Mailing Address - Fax:
Practice Address - Street 1:22820 E APPLEWAY AVE STE A
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019
Practice Address - Country:US
Practice Address - Phone:509-220-3048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60869331363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily