Healthcare Provider Details

I. General information

NPI: 1386407815
Provider Name (Legal Business Name): KATHERINE BROOKE ROSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2024
Last Update Date: 02/06/2024
Certification Date: 02/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 HILLPOINT BLVD N
SUFFOLK VA
23434-8470
US

IV. Provider business mailing address

18421 ORBIT RD
WINDSOR VA
23487-6670
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-2250
  • Fax:
Mailing address:
  • Phone: 757-817-3866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0024182785
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: