Healthcare Provider Details

I. General information

NPI: 1104715135
Provider Name (Legal Business Name): SANDRA LYNN ROSS
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 E MOUNT LOOKOUT RD
MOUNT LOOKOUT WV
26678-9278
US

IV. Provider business mailing address

364 E MOUNT LOOKOUT RD
MOUNT LOOKOUT WV
26678-9278
US

V. Phone/Fax

Practice location:
  • Phone: 304-651-9306
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: