Provider Demographics
NPI:1598255275
Name:ROSE, ELISE (CNM, WHNP)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:CNM, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 SAN MATEO BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1434
Mailing Address - Country:US
Mailing Address - Phone:505-944-2021
Mailing Address - Fax:505-814-5743
Practice Address - Street 1:233 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2116
Practice Address - Country:US
Practice Address - Phone:719-539-7291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0997210-NP367A00000X
WAAP60870938367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000200188Medicaid