Provider Demographics
NPI:1689021651
Name:ROSE, KAYLA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MARIE
Last Name:ROSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 0070
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31603-0070
Mailing Address - Country:US
Mailing Address - Phone:229-433-8160
Mailing Address - Fax:229-244-2707
Practice Address - Street 1:3207 COUNTRY CLUB DRIVE
Practice Address - Street 2:BLDG. B
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1029
Practice Address - Country:US
Practice Address - Phone:229-433-8160
Practice Address - Fax:229-244-2707
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008652363A00000X
NC0010-06635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant