Provider Demographics
NPI:1336477041
Name:PETIT-FRERE, ROSELAINE
Entity Type:Individual
Prefix:MRS
First Name:ROSELAINE
Middle Name:
Last Name:PETIT-FRERE
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 1:3007 11TH STREET S.W.
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33976-2529
Mailing Address - Country:US
Mailing Address - Phone:239-369-2262
Mailing Address - Fax:
Practice Address - Street 1:3007 11TH STREET S.W.
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33976-2529
Practice Address - Country:US
Practice Address - Phone:239-369-2262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA 149036376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6928641 96Medicaid