Provider Demographics
NPI:1114204203
Name:ROSENBERG, STACEY E (CPNP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:E
Last Name:ROSENBERG
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 MOUNT EVEREST WAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5437
Mailing Address - Country:US
Mailing Address - Phone:770-754-5460
Mailing Address - Fax:
Practice Address - Street 1:416 PIRKLE FERRY RD
Practice Address - Street 2:SUITE J300
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-9201
Practice Address - Country:US
Practice Address - Phone:770-889-9297
Practice Address - Fax:770-889-7151
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN146598363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics