Provider Demographics
NPI:1861986242
Name:ROSE, RICHARD LESTER (LPN)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:LESTER
Last Name:ROSE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:LESTER
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:25 BRAINTREE HILL PARK STE 101
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-8715
Mailing Address - Country:US
Mailing Address - Phone:781-971-5019
Mailing Address - Fax:781-817-5821
Practice Address - Street 1:391 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3470
Practice Address - Country:US
Practice Address - Phone:781-971-5018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN65881164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse