Provider Demographics
NPI:1821781048
Name:ROSEBERRY, JOHNDA MICHELLE
Entity Type:Individual
Prefix:
First Name:JOHNDA
Middle Name:MICHELLE
Last Name:ROSEBERRY
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 1:141 ZOAR HILL RD
Mailing Address - Street 2:
Mailing Address - City:COAL GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45638-3066
Mailing Address - Country:US
Mailing Address - Phone:740-764-3259
Mailing Address - Fax:
Practice Address - Street 1:102 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SOUTH POINT
Practice Address - State:OH
Practice Address - Zip Code:45680-9655
Practice Address - Country:US
Practice Address - Phone:740-442-3352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 376K00000X
WV61847376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No374U00000XNursing Service Related ProvidersHome Health Aide