Provider Demographics
NPI:1013583459
Name:ROSE, KELLY KRISTINE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KRISTINE
Last Name:ROSE
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 1:1619 GRACE ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-3800
Mailing Address - Country:US
Mailing Address - Phone:919-896-0214
Mailing Address - Fax:
Practice Address - Street 1:1619 GRACE ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-3800
Practice Address - Country:US
Practice Address - Phone:919-896-0214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional