Provider Demographics
NPI:1558739367
Name:DEROSO, ALICIA (CRNA)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:DEROSO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3470 S SHORE DR
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-9755
Mailing Address - Country:US
Mailing Address - Phone:248-396-3139
Mailing Address - Fax:
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-253-3050
Practice Address - Fax:517-364-3943
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704265519367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered