Provider Demographics
NPI:1801942552
Name:ROSEBERRY, BEVERLY D (APRN)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:D
Last Name:ROSEBERRY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4715
Mailing Address - Street 2:ATLANTA
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30302-4715
Mailing Address - Country:US
Mailing Address - Phone:404-748-4123
Mailing Address - Fax:866-340-9148
Practice Address - Street 1:1733 LAKE ROCKAWAY RD NW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3152
Practice Address - Country:US
Practice Address - Phone:404-748-4123
Practice Address - Fax:866-340-9148
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN065472363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000735314CMedicaid
000735314COtherPEACHSTATE HEALTH PLANS
GA319492OtherWELLCARE
GA10039885OtherAMERIGROUP