Provider Demographics
NPI:1992364020
Name:ROSE, KAYLA M (OD)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:M
Last Name:ROSE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:891 WESTMINSTER ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4020
Mailing Address - Country:US
Mailing Address - Phone:401-331-7850
Mailing Address - Fax:
Practice Address - Street 1:621 POUND HILL RD STE 104
Practice Address - Street 2:
Practice Address - City:NORTH SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02896-9358
Practice Address - Country:US
Practice Address - Phone:401-769-6323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00679152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIBC00404662OtherBLUE CROSS BLUE SHIELD OF RI