Provider Demographics
NPI:1316779945
Name:CLARK, ROSE L
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:L
Last Name:CLARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 W FAIRBANKS AVE STE 218
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4770
Mailing Address - Country:US
Mailing Address - Phone:689-986-5100
Mailing Address - Fax:
Practice Address - Street 1:641 W FAIRBANKS AVE STE 218
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4770
Practice Address - Country:US
Practice Address - Phone:689-986-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA62209225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist