Provider Demographics
NPI:1588101695
Name:ROSE, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:ROSE
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 1:14709 BROUGHAM WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20878-3330
Mailing Address - Country:US
Mailing Address - Phone:301-910-6940
Mailing Address - Fax:
Practice Address - Street 1:14709 BROUGHAM WAY
Practice Address - Street 2:
Practice Address - City:NORTH POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20878-3330
Practice Address - Country:US
Practice Address - Phone:301-910-6940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00584133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered