Provider Demographics
NPI:1134469554
Name:ROSE, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
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 1:8128 N IVORY ROSE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-4050
Mailing Address - Country:US
Mailing Address - Phone:520-572-3908
Mailing Address - Fax:
Practice Address - Street 1:8128 N IVORY ROSE DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-4050
Practice Address - Country:US
Practice Address - Phone:520-572-3908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8419385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8419OtherOLCR LICENSE