Provider Demographics
NPI:1699067702
Name:ROSE, CONSTANCE ANN (CRNP ADULT/GERIATRIC)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:ANN
Last Name:ROSE
Suffix:
Gender:F
Credentials:CRNP ADULT/GERIATRIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1042 PIPISTRELLE CT
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-3842
Mailing Address - Country:US
Mailing Address - Phone:410-688-5390
Mailing Address - Fax:
Practice Address - Street 1:115 E MELROSE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-2945
Practice Address - Country:US
Practice Address - Phone:410-435-9073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-08
Last Update Date:2011-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR173510363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology