Provider Demographics
NPI:1447926332
Name:ROSE, MELINDA BLAIRE
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:BLAIRE
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 1:1505 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3321
Mailing Address - Country:US
Mailing Address - Phone:318-584-7133
Mailing Address - Fax:318-584-7135
Practice Address - Street 1:1505 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3321
Practice Address - Country:US
Practice Address - Phone:318-584-7133
Practice Address - Fax:318-584-7135
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist