Provider Demographics
NPI:1649506445
Name:KIHARA, ROSE (APRN)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:KIHARA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 922
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:CT
Mailing Address - Zip Code:06281-0922
Mailing Address - Country:US
Mailing Address - Phone:860-315-1198
Mailing Address - Fax:603-151-1998
Practice Address - Street 1:39 ROUTE 171
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:CT
Practice Address - Zip Code:06281
Practice Address - Country:US
Practice Address - Phone:860-315-1198
Practice Address - Fax:860-315-1199
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN264473363LF0000X
CT004217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid
CT004235900Medicaid