Provider Demographics
NPI:1093391328
Name:ROSE, ISIS AZIZA
Entity Type:Individual
Prefix:
First Name:ISIS
Middle Name:AZIZA
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 1:903 S COTTAGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-5248
Mailing Address - Country:US
Mailing Address - Phone:217-419-5514
Mailing Address - Fax:
Practice Address - Street 1:903 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-5248
Practice Address - Country:US
Practice Address - Phone:217-419-5514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-18
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No172V00000XOther Service ProvidersCommunity Health Worker