Provider Demographics
NPI:1770167660
Name:ROSE, JOANNA MICHELE (NP)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:MICHELE
Last Name:ROSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:MICHELE
Other - Last Name:HAMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:276 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-2052
Mailing Address - Country:US
Mailing Address - Phone:631-835-6078
Mailing Address - Fax:
Practice Address - Street 1:353 VETERANS MEMORIAL HWY STE 104
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4325
Practice Address - Country:US
Practice Address - Phone:631-498-1344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338740-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily