Provider Demographics
NPI:1831860113
Name:BURCHAM-LAFOUNTAIN, ROSE MICHELLE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:MICHELLE
Last Name:BURCHAM-LAFOUNTAIN
Suffix:
Gender:F
Credentials:
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 904
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-0904
Mailing Address - Country:US
Mailing Address - Phone:701-550-9854
Mailing Address - Fax:
Practice Address - Street 1:1010 1ST ST SE LOT 19
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-4481
Practice Address - Country:US
Practice Address - Phone:701-550-9854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-25
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND693503747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant