Provider Demographics
NPI:1689658031
Name:ROSE, STACY RUTH (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:RUTH
Last Name:ROSE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7590 AUBURN ROAD, SUITE 014
Mailing Address - Street 2:ATTN: MED STAFF
Mailing Address - City:CONCORD TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9176
Mailing Address - Country:US
Mailing Address - Phone:440-354-1899
Mailing Address - Fax:440-354-1845
Practice Address - Street 1:4176 STATE ROUTE 306
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9203
Practice Address - Country:US
Practice Address - Phone:440-918-4630
Practice Address - Fax:440-918-4620
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.06089-NP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2203627Medicaid
OHH020110OtherMEDICARE