Healthcare Provider Details

I. General information

NPI: 1770909236
Provider Name (Legal Business Name): ROSE ROMULUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 05/31/2022
Certification Date: 05/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5825 GLENRIDGE DR BLDG 2 STE 120
ATLANTA GA
30328-5387
US

IV. Provider business mailing address

4439 AUSTELL RD
AUSTELL GA
30106-1839
US

V. Phone/Fax

Practice location:
  • Phone: 404-250-1204
  • Fax: 404-250-1205
Mailing address:
  • Phone: 770-675-7407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN183825
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN183825
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN183825
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN183825
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: