Provider Demographics
NPI:1235849555
Name:ROSE, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
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 1:17180 W SWEETWATER AVE UNIT 1088
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-3404
Mailing Address - Country:US
Mailing Address - Phone:928-671-0904
Mailing Address - Fax:
Practice Address - Street 1:9750 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-4449
Practice Address - Country:US
Practice Address - Phone:928-671-0904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-28
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202209494163W00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163W00000XNursing Service ProvidersRegistered Nurse