Provider Demographics
NPI:1326000985
Name:SIMON, ROSE A (LPN)
Entity type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:A
Last Name:SIMON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:ROSE
Other - Middle Name:A
Other - Last Name:BIRSCHBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:3640 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:LOCKE
Mailing Address - State:NY
Mailing Address - Zip Code:13092-3273
Mailing Address - Country:US
Mailing Address - Phone:315-224-5001
Mailing Address - Fax:315-224-5001
Practice Address - Street 1:138 CECIL MALONE DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5124
Practice Address - Country:US
Practice Address - Phone:607-273-0466
Practice Address - Fax:607-273-0466
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11271-031164W00000X
NY3063031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161413735Medicaid
WI1841595Medicaid