Healthcare Provider Details

I. General information

NPI: 1912693771
Provider Name (Legal Business Name): RAVEN PAULETTE ROSE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2023
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 COBB PKWY NW
ACWORTH GA
30101-4178
US

IV. Provider business mailing address

3809 STONEWALL DR NW
KENNESAW GA
30152-2455
US

V. Phone/Fax

Practice location:
  • Phone: 770-974-3911
  • Fax:
Mailing address:
  • Phone: 404-645-4993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: