MEDICARE: MS. JENETHA RENEE GROSS STNA

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	376K00000X	Nurse's Aide	375204091195	OH

General Provider Information

NPI Number	:	1477883312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENETHA RENEE GROSS STNA

Provider Business Mailing Address
First Line	:	2464 GREENVALE RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44121-1117
Country	:	US
Telephone Number	:	216-773-7665
Fax Number	:

Provider Business Practice Location Address
First Line	:	2464 GREENVALE RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44121-1117
Country	:	US
Telephone Number	:	216-773-7665
Fax Number	:

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

Provider Enumeration Date	:	12/26/2009
Last Update Date	:	12/26/2009

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