Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0505X | Family Doctor - Adult Medicine | RN221014 | GA |
Y | 363L00000X | Nurse Practitioner | RN221014 | GA |
NPI | 1235626003 |
---|---|
Provider Name | Mrs. Andrea A Rose |
First Address | Conyers, GA 30013-2735 |
Second Address | Conyers, GA 30013-2735 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/04/2018 |
Last Update Date | 11/02/2019 |