Provider Demographics
NPI:1235626003
Name:ROSE, ANDREA A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:A
Last Name:ROSE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2796 HIGHWAY 20 SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2735
Mailing Address - Country:US
Mailing Address - Phone:678-374-5134
Mailing Address - Fax:
Practice Address - Street 1:2796 HIGHWAY 20 SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2735
Practice Address - Country:US
Practice Address - Phone:678-374-5134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN221014207QA0505X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine