Provider Demographics
NPI:1104564046
Name:ROSA, KYRA (LMT)
Entity type:Individual
Prefix:
First Name:KYRA
Middle Name:
Last Name:ROSA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:BLENDID
Other - Middle Name:
Other - Last Name:BODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BLENDIDBODY
Mailing Address - Street 1:1175 NW 155TH LN APT 206
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-6327
Mailing Address - Country:US
Mailing Address - Phone:786-859-4606
Mailing Address - Fax:
Practice Address - Street 1:17184 W DIXIE HWY
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33160-5496
Practice Address - Country:US
Practice Address - Phone:786-955-6560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
FLMA77679225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer