Provider Demographics
NPI:1942550868
Name:ROSE, GILLIAN KARA
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:KARA
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 1:36 WENMORE RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1638
Mailing Address - Country:US
Mailing Address - Phone:516-830-1829
Mailing Address - Fax:631-543-2608
Practice Address - Street 1:300 GARDEN CITY PLZ
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-3302
Practice Address - Country:US
Practice Address - Phone:516-747-9030
Practice Address - Fax:516-877-0998
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY566357111174400000X
NY354266091174400000X
NY354265091174400000X
NY501257111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist