Provider Demographics
NPI:1528387974
Name:VIXAMAR, ROSE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:VIXAMAR
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 1:19 RAVENNA DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3607
Mailing Address - Country:US
Mailing Address - Phone:845-426-3120
Mailing Address - Fax:
Practice Address - Street 1:19 RAVENNA DR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3607
Practice Address - Country:US
Practice Address - Phone:845-426-3120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02200527878164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse