Healthcare Provider Details

I. General information

NPI: 1336769934
Provider Name (Legal Business Name): LEAH M ROSE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 08/15/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 COUNTY ROAD 210 W
SAINT JOHNS FL
32259
US

IV. Provider business mailing address

PO BOX 746638
ATLANTA GA
30374-6638
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-4407
  • Fax: 904-390-7459
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11006156
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11006156
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: