Provider Demographics
NPI:1922797620
Name:ROSBACH, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROSBACH
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 1:1800 NOVELL PL
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-6171
Mailing Address - Country:US
Mailing Address - Phone:774-269-2898
Mailing Address - Fax:
Practice Address - Street 1:1152 W 4370 S UNIT 43B
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-2976
Practice Address - Country:US
Practice Address - Phone:774-269-2898
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program