Provider Demographics
NPI:1902209794
Name:BROSE, AMBER (LMT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:BROSE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2271
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-2271
Mailing Address - Country:US
Mailing Address - Phone:808-557-6704
Mailing Address - Fax:
Practice Address - Street 1:68 PUAKO BEACH DR
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-9707
Practice Address - Country:US
Practice Address - Phone:808-557-6704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI12011173C00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No173C00000XOther Service ProvidersReflexologist