Provider Demographics
NPI:1710154075
Name:ROSE, KIMBERLY KAY
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:KAY
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 BIRDIE DR
Mailing Address - Street 2:APT. #3
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-1647
Mailing Address - Country:US
Mailing Address - Phone:901-277-8968
Mailing Address - Fax:
Practice Address - Street 1:421 BIRDIE DR
Practice Address - Street 2:APT. #3
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-1647
Practice Address - Country:US
Practice Address - Phone:901-277-8968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR147802783172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR147802783Medicaid