Provider Demographics
NPI:1407028798
Name:ROSE, KELLI MARIE (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:MARIE
Other - Last Name:PELLMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:1551 BISHOP ST
Practice Address - Street 2:SUITE 520
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4635
Practice Address - Country:US
Practice Address - Phone:805-543-2744
Practice Address - Fax:805-543-0539
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA134727207K00000X
KYR1837207R00000X
390200000X
KY44173207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB235871OtherMEDICARE PTAN
CA1407028798Medicaid