Basic Information
| Provider Information | |||||||||
| NPI: | 1174969232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE-LYNVILLE | ||||||||
| FirstName: | RENEE | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | CAS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 437 | ||||||||
| Address2: | |||||||||
| City: | COLOMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306267252 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 838 BEACH COURT | ||||||||
| Address2: | |||||||||
| City: | LOTUS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306267252 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2013 | ||||||||
| LastUpdateDate: | 05/16/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 03042343 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 03042343 | 01 | CA | CERTIFIED SPECIALIST | OTHER |