Provider Demographics
NPI:1386097541
Name:ROSE, RAQUEL (RDN)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:RAQUEL
Other - Middle Name:
Other - Last Name:REYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:1331 LAFAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-3814
Mailing Address - Country:US
Mailing Address - Phone:503-616-0281
Mailing Address - Fax:
Practice Address - Street 1:2029 SE JEFFERSON ST STE 103
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7605
Practice Address - Country:US
Practice Address - Phone:503-825-0075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN86020670133V00000X
OR10187067133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered