Provider Demographics
NPI:1316164742
Name:ROSE, KATHRYN (WHNP)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 6TH ST
Mailing Address - Street 2:STE 400
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2369
Mailing Address - Country:US
Mailing Address - Phone:231-392-0650
Mailing Address - Fax:231-392-0665
Practice Address - Street 1:1200 6TH ST
Practice Address - Street 2:STE 400
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2369
Practice Address - Country:US
Practice Address - Phone:231-392-0650
Practice Address - Fax:231-392-0665
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704203365363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N30860Medicare PIN