Provider Demographics
NPI:1275717530
Name:ROSE, DONNA L
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:L
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 1:6005 E ABINEAU CANYON DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-7168
Mailing Address - Country:US
Mailing Address - Phone:928-635-6750
Mailing Address - Fax:928-438-3300
Practice Address - Street 1:6005 E ABINEAU CANYON DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-7168
Practice Address - Country:US
Practice Address - Phone:928-635-6750
Practice Address - Fax:928-438-3300
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH-P-6374177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes177F00000XOther Service ProvidersLodging