Provider Demographics
NPI:1679702088
Name:ROSE, HAILEY J (DO)
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:J
Last Name:ROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:HAILEY
Other - Middle Name:J
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX Q
Mailing Address - Street 2:KANIKSU HEALTH SERVICES
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-1200
Mailing Address - Country:US
Mailing Address - Phone:208-267-1718
Mailing Address - Fax:208-267-9197
Practice Address - Street 1:6615 COMANCHE ST
Practice Address - Street 2:KANIKSU HEALTH SERVICES
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805
Practice Address - Country:US
Practice Address - Phone:208-267-1718
Practice Address - Fax:208-267-9197
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL1272208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics