Provider Demographics
NPI:1780053413
Name:ROSE, ELVIRA LILY (LMP)
Entity type:Individual
Prefix:MRS
First Name:ELVIRA
Middle Name:LILY
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2152
Mailing Address - Country:US
Mailing Address - Phone:509-966-3421
Mailing Address - Fax:509-972-0980
Practice Address - Street 1:3808 TIETON DR STE 1
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3691
Practice Address - Country:US
Practice Address - Phone:509-966-3421
Practice Address - Fax:509-972-0980
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60270805225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist