Healthcare Provider Details

I. General information

NPI: 1710695895
Provider Name (Legal Business Name): EUGENNIE GLORIA WILLIAMS-ROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4760 AUSTELL RD STE 3
AUSTELL GA
30106-2007
US

IV. Provider business mailing address

3649 LEAR CT
DOUGLASVILLE GA
30135-7745
US

V. Phone/Fax

Practice location:
  • Phone: 770-726-2477
  • Fax:
Mailing address:
  • Phone: 678-448-8525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10221452
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: