Provider Demographics
NPI:1952916066
Name:ROSALES, TOMMIE M (LPN)
Entity Type:Individual
Prefix:
First Name:TOMMIE
Middle Name:M
Last Name:ROSALES
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 1:3400 W 16TH ST STE P
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6871
Mailing Address - Country:US
Mailing Address - Phone:970-978-4386
Mailing Address - Fax:970-888-3175
Practice Address - Street 1:3400 W 16TH ST STE P
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6871
Practice Address - Country:US
Practice Address - Phone:970-978-4386
Practice Address - Fax:970-888-3175
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPN0043191164W00000X, 164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty