Provider Demographics
NPI:1124141114
Name:ROSE-LIANA, PATRICIA SUE (FNP)
Entity type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:SUE
Last Name:ROSE-LIANA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102, WINTERGREEN
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855
Mailing Address - Country:US
Mailing Address - Phone:906-249-5243
Mailing Address - Fax:
Practice Address - Street 1:425 N GALLOWAY RD
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:MO
Practice Address - Zip Code:63382-1259
Practice Address - Country:US
Practice Address - Phone:573-594-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704109906363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM301359Medicare PIN