Provider Demographics
NPI:1245996644
Name:ROSE, CHARLIE CLUSHETTEA (APRN)
Entity type:Individual
Prefix:MRS
First Name:CHARLIE
Middle Name:CLUSHETTEA
Last Name:ROSE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3042 NATURAL WAY
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-4492
Mailing Address - Country:US
Mailing Address - Phone:270-303-3035
Mailing Address - Fax:
Practice Address - Street 1:811 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-4969
Practice Address - Country:US
Practice Address - Phone:270-904-7029
Practice Address - Fax:270-826-0212
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016967363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily