Provider Demographics
NPI:1710194642
Name:RUBERTINO, ROSALYN ANGIE (RN)
Entity Type:Individual
Prefix:
First Name:ROSALYN
Middle Name:ANGIE
Last Name:RUBERTINO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:44077-5830
Mailing Address - Country:US
Mailing Address - Phone:440-352-7527
Mailing Address - Fax:
Practice Address - Street 1:423 HIGH ST
Practice Address - Street 2:
Practice Address - City:FAIRPORT HARBOR
Practice Address - State:OH
Practice Address - Zip Code:44077-5830
Practice Address - Country:US
Practice Address - Phone:440-352-7527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN147414163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2588365Medicaid