Provider Demographics
NPI:1205947058
Name:ROSE, DENA LYNNE (PT)
Entity type:Individual
Prefix:
First Name:DENA
Middle Name:LYNNE
Last Name:ROSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 VIERSE DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1323
Mailing Address - Country:US
Mailing Address - Phone:573-756-7848
Mailing Address - Fax:
Practice Address - Street 1:109 VIERSE DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1323
Practice Address - Country:US
Practice Address - Phone:573-756-2937
Practice Address - Fax:573-756-2939
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO02200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220811511Medicare ID - Type Unspecified