Provider Demographics
NPI:1437763000
Name:ROSE, NELLIE SUE (LMT)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:SUE
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMT
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 203
Mailing Address - Street 2:
Mailing Address - City:PROSPERITY
Mailing Address - State:WV
Mailing Address - Zip Code:25909-0203
Mailing Address - Country:US
Mailing Address - Phone:304-712-6289
Mailing Address - Fax:
Practice Address - Street 1:21 MALLARD CT
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3615
Practice Address - Country:US
Practice Address - Phone:304-890-8020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2020-3800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist