Basic Information
| Provider Information | |||||||||
| NPI: | 1932471513 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ROSALYN | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN BSN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21951 HARDING ST | ||||||||
| Address2: | |||||||||
| City: | OAK PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482372556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489680564 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2051 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482081105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139613200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2012 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
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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 | 163W00000X | 4704130380 | MI | Y | Nursing Service Providers | Registered Nurse |
No ID Information.