Healthcare Provider Details

I. General information

NPI: 1053723676
Provider Name (Legal Business Name): ANDREA ROCHE GAYDEN ANP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANDREA ROCHE' HAYNES ANP-BC

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 FIVE FORKS TRICKUM RD SW STE 105
LILBURN GA
30047-8975
US

IV. Provider business mailing address

4120 FIVE FORKS TRICKUM RD SW STE 105
LILBURN GA
30047-8975
US

V. Phone/Fax

Practice location:
  • Phone: 770-921-6900
  • Fax:
Mailing address:
  • Phone: 770-921-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberRN208594
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN208594
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: