Healthcare Provider Details

I. General information

NPI: 1962070995
Provider Name (Legal Business Name): KELLY ROSES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2021
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 EDGEGROVE AVE
STATEN ISLAND NY
10312-3312
US

IV. Provider business mailing address

96 EDGEGROVE AVE
STATEN ISLAND NY
10312-3312
US

V. Phone/Fax

Practice location:
  • Phone: 718-696-7717
  • Fax:
Mailing address:
  • Phone: 718-696-7717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1364201191
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: