Provider Demographics
NPI:1275842163
Name:ROSE, KRISTEN JOY (SPEECH LANGUAGE PATH)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:JOY
Last Name:ROSE
Suffix:
Gender:F
Credentials:SPEECH LANGUAGE PATH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1288
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-1288
Mailing Address - Country:US
Mailing Address - Phone:910-671-9629
Mailing Address - Fax:910-671-9630
Practice Address - Street 1:4260 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2711
Practice Address - Country:US
Practice Address - Phone:910-671-9629
Practice Address - Fax:910-671-9630
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8621235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8621OtherSPEECH LANGUAGE PATHOLOGIST