Provider Demographics
NPI:1689124752
Name:DE LA ROSA, LORENA C (FNP-C)
Entity Type:Individual
Prefix:
First Name:LORENA
Middle Name:C
Last Name:DE LA ROSA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1459
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-1459
Mailing Address - Country:US
Mailing Address - Phone:478-538-0908
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN ROAD EAST
Practice Address - Street 2:MAIL ROUTE MN 008-B213
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343
Practice Address - Country:US
Practice Address - Phone:480-216-1993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-12
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132170363LF0000X
AZAP10469363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ296548Medicaid