MEDICARE: MRS. JANE MARIE GROSS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse		WI

General Provider Information

NPI Number	:	1396728929
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JANE MARIE GROSS RN

Provider Business Mailing Address
First Line	:	1625 4 1/2 MILE RD
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53402-1805
Country	:	US
Telephone Number	:	262-681-9072
Fax Number	:

Provider Business Practice Location Address
First Line	:	1625 4 1/2 MILE RD
Second Line	:
City	:	RACINE
State	:	WI
Zip	:	53402-1805
Country	:	US
Telephone Number	:	262-681-9072
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	07/08/2007

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