Basic Information
| Provider Information | |||||||||
| NPI: | 1578629945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROUHET | ||||||||
| FirstName: | ROSA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PALOMO | ||||||||
| OtherFirstName: | ROSA | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8080 STATE ST | ||||||||
| Address2: | |||||||||
| City: | EAST SAINT LOUIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622031808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183973303 | ||||||||
| FaxNumber: | 6183977802 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 UPPER CAHOKIA RD | ||||||||
| Address2: | |||||||||
| City: | CAHOKIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622061212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6183101296 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 04/30/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041275771 | IL | N | Nursing Service Providers | Registered Nurse | 163W00000X | 124452 | MO | N | Nursing Service Providers | Registered Nurse | 363L00000X | 209006099 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 124452 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.