Provider Demographics
NPI:1629831771
Name:ROSA, NICOLE AGNES (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:AGNES
Last Name:ROSA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4907 STONECREST DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2479
Mailing Address - Country:US
Mailing Address - Phone:813-486-3376
Mailing Address - Fax:
Practice Address - Street 1:3615 S FLORIDA AVE STE 460
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-4871
Practice Address - Country:US
Practice Address - Phone:863-940-2091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6414152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist