Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | AT8276 | CA |
NPI | 1003026311 |
---|---|
Provider Name | Kellyanne Rose |
First Address | San Diego, CA 92103-7625 |
Second Address | La Mesa, CA 91942-3307 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/05/2007 |
Last Update Date | 08/07/2007 |