Provider Demographics
NPI:1295249522
Name:ROSE, KRISTINA BEA
Entity type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:BEA
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 1:211 FAIRWOOD PL
Mailing Address - Street 2:
Mailing Address - City:ROCKTON
Mailing Address - State:IL
Mailing Address - Zip Code:61072-2951
Mailing Address - Country:US
Mailing Address - Phone:815-742-8274
Mailing Address - Fax:
Practice Address - Street 1:2400 N ROCKTON AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3655
Practice Address - Country:US
Practice Address - Phone:815-968-6861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.002698225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics