Basic Information
| Provider Information | |||||||||
| NPI: | 1750318788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD, GCNS-BC, PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2077 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972082077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | LEGACY SALMON CREEK PROVIDERS | ||||||||
| Address2: | 2211 NE 139TH STREET | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986862742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034138407 | ||||||||
| FaxNumber: | 5034136951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 200850041NP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364SG0600X | 200470003 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Gerontology | 363LP0808X | AP60031978 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | G8878364 | 01 | WA | MEDICARE | OTHER |