Provider Demographics
NPI:1972339067
Name:ROSE, ANGY (PT)
Entity type:Individual
Prefix:
First Name:ANGY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1393
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1393
Mailing Address - Country:US
Mailing Address - Phone:501-326-1984
Mailing Address - Fax:
Practice Address - Street 1:280 WOLF ST
Practice Address - Street 2:
Practice Address - City:PEARCY
Practice Address - State:AR
Practice Address - Zip Code:71964-9449
Practice Address - Country:US
Practice Address - Phone:501-326-1984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1469225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist