Provider Demographics
NPI:1720795289
Name:ROESE, AMBER LESLIE (SW INTERN)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:LESLIE
Last Name:ROESE
Suffix:
Gender:F
Credentials:SW INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10-42 MITCHELL AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-1617
Mailing Address - Country:US
Mailing Address - Phone:607-762-2340
Mailing Address - Fax:
Practice Address - Street 1:10-42 MITCHELL AVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1617
Practice Address - Country:US
Practice Address - Phone:607-762-2340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program