Provider Demographics
NPI:1922559244
Name:ROSEBORO, JACQUELINE (AGCNS-BC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ROSEBORO
Suffix:
Gender:F
Credentials:AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10511 ATKINS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4296
Mailing Address - Country:US
Mailing Address - Phone:704-473-6455
Mailing Address - Fax:
Practice Address - Street 1:10511 ATKINS RIDGE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-4296
Practice Address - Country:US
Practice Address - Phone:704-473-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC185443163W00000X
NC2015005693364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse