Provider Demographics
NPI:1992238497
Name:MARSHALL, ROSE MCDONALD
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:MCDONALD
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:MARIE
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2626 EAST 82ND STREET
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4503
Mailing Address - Country:US
Mailing Address - Phone:952-814-7400
Mailing Address - Fax:952-853-0966
Practice Address - Street 1:2626 EAST 82ND STREET
Practice Address - Street 2:SUITE 180
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-4503
Practice Address - Country:US
Practice Address - Phone:952-814-7400
Practice Address - Fax:952-853-0966
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR168412-4163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA114982000Medicaid