Provider Demographics
NPI:1922697572
Name:ROSE, NICOLE E
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:SKUDLAREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:574-647-6592
Mailing Address - Fax:
Practice Address - Street 1:5314 LINCOLNWAY E
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-4249
Practice Address - Country:US
Practice Address - Phone:574-584-2812
Practice Address - Fax:574-584-2813
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010889A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300047896Medicaid