Provider Demographics
NPI:1063140101
Name:YOUNG, MIALARA ROSE (LMT, LAC)
Entity type:Individual
Prefix:MRS
First Name:MIALARA
Middle Name:ROSE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:LMT, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 WESTRAC DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8716
Mailing Address - Country:US
Mailing Address - Phone:701-297-8191
Mailing Address - Fax:
Practice Address - Street 1:1121 WESTRAC DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8716
Practice Address - Country:US
Practice Address - Phone:701-297-8191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-08
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2007171100000X
ND2023-06171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist