Provider Demographics
NPI:1639951528
Name:PORTILLO, ROSA MARIA (FNP-C)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:MARIA
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 20TH AVE SW # 1
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-6452
Mailing Address - Country:US
Mailing Address - Phone:469-583-0709
Mailing Address - Fax:
Practice Address - Street 1:1324 20TH AVE SW # 1
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-6452
Practice Address - Country:US
Practice Address - Phone:701-838-6000
Practice Address - Fax:701-838-6624
Is Sole Proprietor?:No
Enumeration Date:2023-10-16
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11029002363LF0000X
ND200494363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily