Provider Demographics
NPI:1750829024
Name:SURPRISE, ROSE MYRLENE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MYRLENE
Last Name:SURPRISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 S COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:BELLPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11713-2523
Mailing Address - Country:US
Mailing Address - Phone:631-286-2222
Mailing Address - Fax:
Practice Address - Street 1:107 S COUNTRY RD
Practice Address - Street 2:
Practice Address - City:BELLPORT
Practice Address - State:NY
Practice Address - Zip Code:11713-2523
Practice Address - Country:US
Practice Address - Phone:631-286-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-07
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340052-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01259347Medicaid