Provider Demographics
NPI:1821548884
Name:ROSE, ABIGAIL
Entity Type:Individual
Prefix:
First Name:ABIGAIL
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 1:152 VAN BUREN STREET EXT
Mailing Address - Street 2:
Mailing Address - City:DOLGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13329-1411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:152 VAN BUREN STREET EXT
Practice Address - Street 2:
Practice Address - City:DOLGEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13329-1411
Practice Address - Country:US
Practice Address - Phone:518-332-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 3751171100000X
NY006355171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist