Provider Demographics
NPI:1295902609
Name:BROWN, ROSE MARY (BS MS RD)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:MARY
Last Name:BROWN
Suffix:
Gender:F
Credentials:BS MS RD
Other - Prefix:
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Mailing Address - Street 1:909 N BROADWAY
Mailing Address - Street 2:PBO
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1409
Mailing Address - Country:US
Mailing Address - Phone:425-317-0264
Mailing Address - Fax:425-317-0291
Practice Address - Street 1:916 PACIFIC AVENUE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201
Practice Address - Country:US
Practice Address - Phone:425-303-6500
Practice Address - Fax:425-303-6550
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WADI00001834132700000X, 133V00000X, 133VN1004X, 133VN1005X, 133VN1006X, 136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADI00001834OtherWA ST PROFESSIONAL LICENSE
WADI00001834OtherWA ST PROFESSIONAL LICENSE
WAG8878193Medicare PIN