Provider Demographics
NPI:1063193654
Name:ROSTA, SUSAN DIANE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:ROSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:DIANE
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 BROOKSEDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3394
Mailing Address - Country:US
Mailing Address - Phone:614-882-9338
Mailing Address - Fax:614-898-5137
Practice Address - Street 1:700 BROOKSEDGE BLVD
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-3394
Practice Address - Country:US
Practice Address - Phone:614-882-9338
Practice Address - Fax:614-898-5137
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH199578163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse