Provider Demographics
NPI:1336848670
Name:ROSE, LYDIA ELSIE (MED)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:ELSIE
Last Name:ROSE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:MRS
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:ROSE-ADORNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED
Mailing Address - Street 1:14 BRIGHTON DR UNIT 2604
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-7453
Mailing Address - Country:US
Mailing Address - Phone:845-549-0738
Mailing Address - Fax:
Practice Address - Street 1:280 ROUTE 211 E STE 104-300
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-3109
Practice Address - Country:US
Practice Address - Phone:845-769-8179
Practice Address - Fax:845-913-9410
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY848459981174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist