Provider Demographics
NPI:1679094114
Name:ROSE, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4440 GENTLE KNOLL DR S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-4158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4000 CENTRAL FLORIDA BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32816-8005
Practice Address - Country:US
Practice Address - Phone:407-823-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program