Provider Demographics
NPI:1447863857
Name:ROSALES, OLIVIA GRACE
Entity type:Individual
Prefix:MISS
First Name:OLIVIA
Middle Name:GRACE
Last Name:ROSALES
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 1:4636 E SANDRA TER
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3438
Mailing Address - Country:US
Mailing Address - Phone:602-319-8347
Mailing Address - Fax:
Practice Address - Street 1:208 E PINE KNOLL DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86011-0001
Practice Address - Country:US
Practice Address - Phone:928-523-7147
Practice Address - Fax:928-523-6195
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program