Provider Demographics
NPI:1710441951
Name:ROSE, EBONY TARYN (MS, LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:EBONY
Middle Name:TARYN
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 HINGE CHASE
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-3375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1585 3RD ST
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT81232255A2300X
OHAT0059002255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer