Provider Demographics
NPI:1417378449
Name:ROSE, AUDREY (AG-ACNP)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 BOSTON PROVIDENCE TPKE
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-4655
Mailing Address - Country:US
Mailing Address - Phone:781-440-9911
Mailing Address - Fax:
Practice Address - Street 1:1418 BOSTON PROVIDENCE TPKE
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-4655
Practice Address - Country:US
Practice Address - Phone:781-440-9911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-17
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2260692363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care