Healthcare Provider Details

I. General information

NPI: 1306505896
Provider Name (Legal Business Name): NICOLE M ROSS CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2021
Last Update Date: 12/11/2021
Certification Date: 12/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3129 OHIO ST
KENNER LA
70065-4436
US

IV. Provider business mailing address

6149 S HERMES ST
NEW ORLEANS LA
70126-2636
US

V. Phone/Fax

Practice location:
  • Phone: 985-288-7269
  • Fax:
Mailing address:
  • Phone: 985-288-7269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number88424
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberA063444
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: