Provider Demographics
NPI:1356014583
Name:ROSA, NERSYMARTH A
Entity Type:Individual
Prefix:
First Name:NERSYMARTH
Middle Name:A
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 1:5134 MINA CIR APT 101
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-7859
Mailing Address - Country:US
Mailing Address - Phone:239-810-6718
Mailing Address - Fax:
Practice Address - Street 1:5134 MINA CIRCLE APT 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905
Practice Address - Country:US
Practice Address - Phone:239-810-6718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-25
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH23803124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist