Provider Demographics
NPI:1336174499
Name:ROSE, KELLIE ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:ANNE
Last Name:ROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1462 MONTREAL RD
Mailing Address - Street 2:STE 201
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6931
Mailing Address - Country:US
Mailing Address - Phone:404-299-6488
Mailing Address - Fax:
Practice Address - Street 1:2675 N DECATUR RD
Practice Address - Street 2:SUITE 701
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6131
Practice Address - Country:US
Practice Address - Phone:404-299-6488
Practice Address - Fax:404-299-7522
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033060174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00653045BMedicaid
GAG02615Medicare UPIN
GA77BBBJMMedicare ID - Type Unspecified