Healthcare Provider Details

I. General information

NPI: 1285326843
Provider Name (Legal Business Name): ANGELA ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2023
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 N MAIN ST
LAYTON UT
84041-4800
US

IV. Provider business mailing address

1100 S 2000 E APT M2003
CLEARFIELD UT
84015-6218
US

V. Phone/Fax

Practice location:
  • Phone: 801-663-6109
  • Fax:
Mailing address:
  • Phone: 801-663-6109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number6389050-4701
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: