Provider Demographics
NPI:1003183229
Name:ROSE, ELAINE RENEE (IBCLC)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:RENEE
Last Name:ROSE
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12345 HEATHER ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-1754
Mailing Address - Country:US
Mailing Address - Phone:612-963-1301
Mailing Address - Fax:
Practice Address - Street 1:12345 HEATHER ST NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-1754
Practice Address - Country:US
Practice Address - Phone:612-963-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN