Provider Demographics
NPI:1386362861
Name:ROSE, ANGELA GAIL (PTA)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:GAIL
Last Name:ROSE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10857 HUESEMAN RD
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IN
Mailing Address - Zip Code:47001-2213
Mailing Address - Country:US
Mailing Address - Phone:513-460-5702
Mailing Address - Fax:
Practice Address - Street 1:405 RIO VISTA LN
Practice Address - Street 2:
Practice Address - City:RISING SUN
Practice Address - State:IN
Practice Address - Zip Code:47040-9497
Practice Address - Country:US
Practice Address - Phone:812-438-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06000923A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant