Provider Demographics
NPI:1356009765
Name:ROSE, CHANDA M (FNP)
Entity Type:Individual
Prefix:
First Name:CHANDA
Middle Name:M
Last Name:ROSE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:117 CAMINO DE VIDA STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88435-2267
Mailing Address - Country:US
Mailing Address - Phone:575-472-4311
Mailing Address - Fax:877-651-0289
Practice Address - Street 1:220 S 3RD ST
Practice Address - Street 2:
Practice Address - City:TUCUMCARI
Practice Address - State:NM
Practice Address - Zip Code:88401-2802
Practice Address - Country:US
Practice Address - Phone:575-461-8631
Practice Address - Fax:888-708-0683
Is Sole Proprietor?:No
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMCNP-66220363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily