Provider Demographics
NPI:1174402192
Name:BLACK, ROSE
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:BLACK
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 1:5361 AVERY CREEK LN
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-8402
Mailing Address - Country:US
Mailing Address - Phone:614-214-5418
Mailing Address - Fax:
Practice Address - Street 1:5361 AVERY CREEK LN
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-8402
Practice Address - Country:US
Practice Address - Phone:614-214-5418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker