Provider Demographics
NPI:1992177802
Name:JOSE, ANUPAMA
Entity Type:Individual
Prefix:
First Name:ANUPAMA
Middle Name:
Last Name:JOSE
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 1:444 ROXBURY RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5059
Mailing Address - Country:US
Mailing Address - Phone:815-398-3000
Mailing Address - Fax:815-398-3041
Practice Address - Street 1:444 ROXBURY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5059
Practice Address - Country:US
Practice Address - Phone:815-398-3000
Practice Address - Fax:815-398-3041
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-013262363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner