Provider Demographics
NPI:1629788906
Name:WAKANABO, ROSETTE (RN)
Entity type:Individual
Prefix:
First Name:ROSETTE
Middle Name:
Last Name:WAKANABO
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3214 MAIN CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-8627
Mailing Address - Country:US
Mailing Address - Phone:508-371-8503
Mailing Address - Fax:
Practice Address - Street 1:3214 MAIN CAMPUS DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-8627
Practice Address - Country:US
Practice Address - Phone:508-371-8503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2320331163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse