Provider Demographics
NPI:1972942951
Name:GUILLEN, ROSA G (BA)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:G
Last Name:GUILLEN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5615 GARDEN GROVE CIR
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-7326
Mailing Address - Country:US
Mailing Address - Phone:407-247-5470
Mailing Address - Fax:
Practice Address - Street 1:5615 GARDEN GROVE CIR
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-7326
Practice Address - Country:US
Practice Address - Phone:407-247-5470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-23
Last Update Date:2013-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL171M00000XMedicaid