Provider Demographics
NPI:1184734980
Name:ROSETE-LASALA, GRACE LEYSON
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:LEYSON
Last Name:ROSETE-LASALA
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 1:9938 ALLEN POINT DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101
Mailing Address - Country:US
Mailing Address - Phone:313-928-4475
Mailing Address - Fax:
Practice Address - Street 1:26001 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127
Practice Address - Country:US
Practice Address - Phone:313-274-4600
Practice Address - Fax:313-274-4079
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704230094363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner