=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336174499
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLIE ANNE ROSE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 06/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2675 N DECATUR RD SUITE 701
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30033-6131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-299-6488
-----------------------------------------------------
Fax | 404-299-7522
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1462 MONTREAL RD STE 201
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-6931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-299-6488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 033060
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------