Provider Demographics
NPI:1275120842
Name:GANIM, ROSEANNE BERNADETTE
Entity Type:Individual
Prefix:
First Name:ROSEANNE
Middle Name:BERNADETTE
Last Name:GANIM
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 1:1425 BARNUM AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5429
Mailing Address - Country:US
Mailing Address - Phone:203-383-7741
Mailing Address - Fax:
Practice Address - Street 1:110 BEACHVIEW AVE # CONDO222
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-3262
Practice Address - Country:US
Practice Address - Phone:203-218-0275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE49092163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management