Provider Demographics
NPI:1255908471
Name:VARNUM, ROSE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:VARNUM
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 1:12227 N LAKE GARDEN DR
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34434-2036
Mailing Address - Country:US
Mailing Address - Phone:352-362-1217
Mailing Address - Fax:
Practice Address - Street 1:8733 W YULEE DR
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34448-4222
Practice Address - Country:US
Practice Address - Phone:352-621-8017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19893225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant