Provider Demographics
NPI:1275193450
Name:ROSA, TRICIA KAY
Entity Type:Individual
Prefix:MRS
First Name:TRICIA
Middle Name:KAY
Last Name: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 1:20095 GILBERT RD
Mailing Address - Street 2:STE B
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-2366
Mailing Address - Country:US
Mailing Address - Phone:517-937-5769
Mailing Address - Fax:
Practice Address - Street 1:6767 KNOLLVIEW DR
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-9388
Practice Address - Country:US
Practice Address - Phone:517-937-5769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278243163WG0000X, 363LF0000X
KY3017093363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice