Healthcare Provider Details

I. General information

NPI: 1487767646
Provider Name (Legal Business Name): KATHY LEYVONNE ROSS ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL DRIVE
CLARKSBURG WV
26301
US

IV. Provider business mailing address

1 MEDICAL DRIVE
CLARKSBURG WV
26301
US

V. Phone/Fax

Practice location:
  • Phone: 304-623-3461
  • Fax: 304-623-7683
Mailing address:
  • Phone: 304-623-3461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21472
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: