Provider Demographics
NPI:1982385654
Name:IFEDIORA, ROSE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:IFEDIORA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:N
Other - Last Name:IFEDIORA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2636 SAGEBRUSH DR
Mailing Address - Street 2:
Mailing Address - City:GLENN HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:75154-1890
Mailing Address - Country:US
Mailing Address - Phone:940-400-9135
Mailing Address - Fax:
Practice Address - Street 1:1420 N COOPER ST STE 110A
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-8530
Practice Address - Country:US
Practice Address - Phone:972-204-5805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF07230637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily