Healthcare Provider Details

I. General information

NPI: 1750355178
Provider Name (Legal Business Name): THERESA ANN ROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11050 MOUNT BELVEDERE BLVD USA MEDDAC ATTN CREDENTIALS
FORT DRUM NY
13602-5438
US

IV. Provider business mailing address

12301 COLBY LAKE RD PO BOX 568
LAINGSBURG MI
48848-9313
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-4025
  • Fax: 315-772-9498
Mailing address:
  • Phone: 517-290-3875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number4704123246
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: