Provider Demographics
NPI:1356379028
Name:HARRELL, ROSETTA A (APN)
Entity type:Individual
Prefix:
First Name:ROSETTA
Middle Name:A
Last Name:HARRELL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E 8TH ST
Mailing Address - Street 2:STE. A
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-1443
Mailing Address - Country:US
Mailing Address - Phone:574-223-8565
Mailing Address - Fax:574-223-8786
Practice Address - Street 1:401 E 8TH ST
Practice Address - Street 2:STE. A
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-1443
Practice Address - Country:US
Practice Address - Phone:574-223-8565
Practice Address - Fax:574-223-8786
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000027A364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP99523Medicare UPIN
IN111810BBMedicare ID - Type Unspecified