Provider Demographics
NPI:1750318788
Name:ROSE, SUSAN S (PHD, GCNS-BC, PMHNP)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:S
Last Name:ROSE
Suffix:
Gender:
Credentials:PHD, GCNS-BC, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 873473
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98687-3473
Mailing Address - Country:US
Mailing Address - Phone:971-258-0854
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 873473
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98687-3473
Practice Address - Country:US
Practice Address - Phone:971-258-0854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200850041NP363LP0808X
OR200470003364SG0600X
WAAP60031978363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8878364OtherMEDICARE