Provider Demographics
NPI:1760038210
Name:MAI, ROSANNA (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:ROSANNA
Middle Name:
Last Name:MAI
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:ROSANNA
Other - Middle Name:
Other - Last Name:CHHUOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:113 S HALE AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2737
Mailing Address - Country:US
Mailing Address - Phone:813-486-0491
Mailing Address - Fax:
Practice Address - Street 1:4315 HIGHLAND PARK BLVD STE A
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-1639
Practice Address - Country:US
Practice Address - Phone:863-816-5884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-12
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9315955363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLO3RLAOtherBLUE CROSS BLUE SHIELD
FL113202900Medicaid