Provider Demographics
NPI:1467524462
Name:ROSEN, ANGELA IVY (LAC)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:IVY
Last Name:ROSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 HANNA WAY
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-3581
Mailing Address - Country:US
Mailing Address - Phone:510-517-6858
Mailing Address - Fax:
Practice Address - Street 1:1911 ADDISON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-1267
Practice Address - Country:US
Practice Address - Phone:510-517-6858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2012-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10848171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist