Provider Demographics
NPI:1437875879
Name:MOORE, ROSLYN
Entity type:Individual
Prefix:
First Name:ROSLYN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 OLD PEACHTREE RD NW
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-2511
Mailing Address - Country:US
Mailing Address - Phone:678-937-0300
Mailing Address - Fax:781-464-2599
Practice Address - Street 1:334 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5533
Practice Address - Country:US
Practice Address - Phone:229-227-1595
Practice Address - Fax:229-227-1385
Is Sole Proprietor?:No
Enumeration Date:2022-10-18
Last Update Date:2025-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPRN-NP105131363L00000X
GARN105131363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology