Provider Demographics
NPI:1508090440
Name:FAYETTE, ROSE M (ANP-BC)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:FAYETTE
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:MA
Mailing Address - Zip Code:02322-1869
Mailing Address - Country:US
Mailing Address - Phone:617-763-8526
Mailing Address - Fax:
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-4927
Practice Address - Country:US
Practice Address - Phone:857-203-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-06
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN230374363LA2200X
MA230374282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health