Provider Demographics
NPI:1346630605
Name:ROSE, KATHARINE BANNING (EDM, AT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:KATHARINE
Middle Name:BANNING
Last Name:ROSE
Suffix:
Gender:F
Credentials:EDM, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 FAIRBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3735
Mailing Address - Country:US
Mailing Address - Phone:815-757-7287
Mailing Address - Fax:
Practice Address - Street 1:222 FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3735
Practice Address - Country:US
Practice Address - Phone:815-757-7287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010012562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer