Basic Information
| Provider Information | |||||||||
| NPI: | 1689658031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7590 AUBURN ROAD, SUITE 014 | ||||||||
| Address2: | ATTN: MED STAFF | ||||||||
| City: | CONCORD TWP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440779176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403541899 | ||||||||
| FaxNumber: | 4403541845 | ||||||||
| Practice Location | |||||||||
| Address1: | 4176 STATE ROUTE 306 | ||||||||
| Address2: | |||||||||
| City: | WILLOUGHBY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440949203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409184630 | ||||||||
| FaxNumber: | 4409184620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | COA.06089-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 2203627 | 05 | OH | MEDICAID | H020110 | 01 | OH | MEDICARE | OTHER |