Provider Demographics
NPI:1992995559
Name:ROSE, KRISTINA MARIE (LMP)
Entity type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:MARIE
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMP
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 1004
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-1004
Mailing Address - Country:US
Mailing Address - Phone:360-462-2639
Mailing Address - Fax:
Practice Address - Street 1:104 E D ST STE 2
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2122
Practice Address - Country:US
Practice Address - Phone:360-462-2639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA22099174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist