Basic Information
| Provider Information | |||||||||
| NPI: | 1295325132 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSSO | ||||||||
| FirstName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 191 IVY STONE DR | ||||||||
| Address2: | |||||||||
| City: | RAEFORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283767383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608709971 | ||||||||
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| Practice Location | |||||||||
| Address1: | C, 1722 TAGATAY DRIVE | ||||||||
| Address2: | |||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078282 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2021 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.