Provider Demographics
NPI:1740081488
Name:DEVALLON, ROSE B (NP)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:B
Last Name:DEVALLON
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:ROSE-BERLINE
Other - Middle Name:
Other - Last Name:DEVALLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10202 NEW BEDFORD CT
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92040-2352
Mailing Address - Country:US
Mailing Address - Phone:224-545-1690
Mailing Address - Fax:
Practice Address - Street 1:307 TRENT DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-3038
Practice Address - Country:US
Practice Address - Phone:224-545-1690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9586378363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health