Provider Demographics
NPI:1023642949
Name:ROSE, KATIE MICHELLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:MICHELLE
Last Name:ROSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:MICHELLE
Other - Last Name:GUNNARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1639 N ALPINE RD STE 360
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1440
Mailing Address - Country:US
Mailing Address - Phone:515-979-9508
Mailing Address - Fax:
Practice Address - Street 1:1639 N ALPINE RD STE 360
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1440
Practice Address - Country:US
Practice Address - Phone:815-229-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-29
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
IL085.008991363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program