Provider Demographics
NPI:1902504459
Name:SMALL, ROSELYN
Entity Type:Individual
Prefix:
First Name:ROSELYN
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24506
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-1506
Mailing Address - Country:US
Mailing Address - Phone:817-627-4735
Mailing Address - Fax:
Practice Address - Street 1:6850 MANHATTAN BLVD STE 300-25
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76120-1227
Practice Address - Country:US
Practice Address - Phone:817-627-4735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No251E00000XAgenciesHome Health
No171W00000XOther Service ProvidersContractor
No253Z00000XAgenciesIn Home Supportive Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No376J00000XNursing Service Related ProvidersHomemaker