Healthcare Provider Details

I. General information

NPI: 1346006699
Provider Name (Legal Business Name): CLAYTON KENNETH ROSE AGACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2024
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5665 PEACHTREE DUNWOODY RD
ATLANTA GA
30342-1764
US

IV. Provider business mailing address

216 LITTLE BROOK LN
WOODSTOCK GA
30188-1938
US

V. Phone/Fax

Practice location:
  • Phone: 678-843-7001
  • Fax:
Mailing address:
  • Phone: 770-866-8453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNP290383
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN290383
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: