Provider Demographics
NPI:1083859250
Name:NEPTUNE, ROSE KIDD
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:KIDD
Last Name:NEPTUNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:MARY
Other - Last Name:KIDD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1715 GRIFFIN AVE
Mailing Address - Street 2:PREMATURE INFANT CLINIC, BLDG. 60
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-3312
Mailing Address - Country:US
Mailing Address - Phone:323-226-3237
Mailing Address - Fax:323-226-4263
Practice Address - Street 1:1715 GRIFFIN AVE
Practice Address - Street 2:PREMATURE INFANT CLINIC, BLDG. 60
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-3312
Practice Address - Country:US
Practice Address - Phone:323-226-3237
Practice Address - Fax:323-226-4263
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11960363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant