Provider Demographics
NPI:1063272524
Name:ROSE, FREDRIEKA ALICIA LATOYA
Entity type:Individual
Prefix:
First Name:FREDRIEKA
Middle Name:ALICIA LATOYA
Last Name:ROSE
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 1:7751 NW 41ST ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-8415
Mailing Address - Country:US
Mailing Address - Phone:954-643-0278
Mailing Address - Fax:
Practice Address - Street 1:5304 MILE STRETCH DR
Practice Address - Street 2:
Practice Address - City:HOLIDAY
Practice Address - State:FL
Practice Address - Zip Code:34690-6060
Practice Address - Country:US
Practice Address - Phone:877-202-1191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9305674363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health