Healthcare Provider Details

I. General information

NPI: 1417378449
Provider Name (Legal Business Name): AUDREY ROSE AG-ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 TRADECENTER
WOBURN MA
01801-1883
US

IV. Provider business mailing address

1418 BOSTON PROVIDENCE TPKE
NORWOOD MA
02062-4655
US

V. Phone/Fax

Practice location:
  • Phone: 781-632-0576
  • Fax: 603-341-7778
Mailing address:
  • Phone: 781-440-9911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN2260692
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: