Provider Demographics
NPI:1710551270
Name:ROSE, KEOSHA
Entity Type:Individual
Prefix:
First Name:KEOSHA
Middle Name:
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 1:14431 W DAVID DR APT B
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-1202
Mailing Address - Country:US
Mailing Address - Phone:504-296-9865
Mailing Address - Fax:
Practice Address - Street 1:14431 W DAVID DR APT B
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-1202
Practice Address - Country:US
Practice Address - Phone:504-296-9865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty