Provider Demographics
NPI:1558160697
Name:ROSE, ABIGAIL (MS, RD)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 HARMONY HL
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-4523
Mailing Address - Country:US
Mailing Address - Phone:618-535-7127
Mailing Address - Fax:
Practice Address - Street 1:1107 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2600
Practice Address - Country:US
Practice Address - Phone:217-214-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024043882133V00000X
IL164007205133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered