Provider Demographics
NPI:1295235265
Name:ROSE, MERRY J (LPN)
Entity type:Individual
Prefix:
First Name:MERRY
Middle Name:J
Last Name:ROSE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-4557
Mailing Address - Country:US
Mailing Address - Phone:407-252-6314
Mailing Address - Fax:
Practice Address - Street 1:207 PARK PLACE BLVD STE 2
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2373
Practice Address - Country:US
Practice Address - Phone:407-870-5050
Practice Address - Fax:407-870-7609
Is Sole Proprietor?:No
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5228549164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPN5228549OtherLPN LICENSE