Provider Demographics
NPI:1841942471
Name:ROSEBURGH, NICKI NACOLE (LPN)
Entity type:Individual
Prefix:
First Name:NICKI
Middle Name:NACOLE
Last Name:ROSEBURGH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4214 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:OH
Mailing Address - Zip Code:43213-3028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6895 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2289
Practice Address - Country:US
Practice Address - Phone:614-334-6903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH168132164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse