Healthcare Provider Details

I. General information

NPI: 1720141112
Provider Name (Legal Business Name): ELIZABETH MARY ROSS D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELIZABETH MARY HARKNESS D.O.

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 PARK TERRACE DR
ST AUGUSTINE FL
32080-5334
US

IV. Provider business mailing address

22 PARK TERRACE DR
ST AUGUSTINE FL
32080-5334
US

V. Phone/Fax

Practice location:
  • Phone: 904-347-8470
  • Fax:
Mailing address:
  • Phone: 904-347-8470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberUO1279
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: