Provider Demographics
NPI:1871754093
Name:ROOSEVELT, ROSE M (RN)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:M
Last Name:ROOSEVELT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5878 SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5281
Mailing Address - Country:US
Mailing Address - Phone:404-543-1199
Mailing Address - Fax:
Practice Address - Street 1:5878 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-5281
Practice Address - Country:US
Practice Address - Phone:404-543-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA163WE0003X163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency