Provider Demographics
NPI:1578995718
Name:ROSE, CHARLETTE (LMP LAC)
Entity Type:Individual
Prefix:
First Name:CHARLETTE
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMP LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8060 165TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3981
Mailing Address - Country:US
Mailing Address - Phone:206-753-7430
Mailing Address - Fax:
Practice Address - Street 1:8060 165TH AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3981
Practice Address - Country:US
Practice Address - Phone:206-753-7430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-30
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010790174400000X
WAAC00001878171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No174400000XOther Service ProvidersSpecialist