Individual
MR. RILEY D ROSE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
AG/ACNP
Contact information
Practice address
1406 W BELLA DR, MARION, IN 46953-5229
(765) 660-7720
(765) 662-4493
Mailing address
330 N WABASH AVE, STE G20, MARION, IN 46952-2696
(765) 660-7600
(765) 651-7313
Taxonomy
Speciality
Code
Description
License number
State
163WW0000X
Wound Care Registered Nurse
28161345A
IN
363LA2100X
Acute Care Nurse Practitioner
Primary
741004600A
IN
363LG0600X
Gerontology Nurse Practitioner
741004600A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000878522
ANTHEM
IN
05
—
201202120A
—
IN
Enumeration date
09/13/2013
Last updated
10/21/2020
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