Provider Demographics
NPI:1134805674
Name:DE LA ROSA, BEVERLY A
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:A
Last Name:DE LA ROSA
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 1:4005 FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-8058
Mailing Address - Country:US
Mailing Address - Phone:910-848-5437
Mailing Address - Fax:
Practice Address - Street 1:4005 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-8058
Practice Address - Country:US
Practice Address - Phone:910-848-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC5018560363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program