Provider Demographics
NPI:1194804815
Name:ROSA, NICHOLE A (CRNP)
Entity type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:A
Last Name:ROSA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:A
Other - Last Name:MACCONNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:433 CHURCH ST
Mailing Address - Street 2:P.O. BOX 602
Mailing Address - City:NEW MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18834-6603
Mailing Address - Country:US
Mailing Address - Phone:570-465-4500
Mailing Address - Fax:570-465-4501
Practice Address - Street 1:433 CHURCH ST
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18834-6603
Practice Address - Country:US
Practice Address - Phone:570-465-4500
Practice Address - Fax:570-465-4501
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334797363LF0000X
PASP009050363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily