Healthcare Provider Details

I. General information

NPI: 1669936258
Provider Name (Legal Business Name): MARINA B ROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 SKYLINE DR STE 1
LADY LAKE FL
32159-4592
US

IV. Provider business mailing address

104 E DIXIE AVE
LEESBURG FL
34748-6350
US

V. Phone/Fax

Practice location:
  • Phone: 352-431-3940
  • Fax: 352-431-3173
Mailing address:
  • Phone: 352-431-3940
  • Fax: 352-431-3173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0810X
TaxonomyChild & Family Psychiatric/Mental Health Clinical Nurse Specialist
License NumberAPRN11001032
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: