Provider Demographics
NPI:1063539823
Name:VAN ROSS, SYREETA LYNN
Entity type:Individual
Prefix:
First Name:SYREETA
Middle Name:LYNN
Last Name:VAN ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SYREETA
Other - Middle Name:LYNN
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 740019
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0019
Mailing Address - Country:US
Mailing Address - Phone:773-644-3941
Mailing Address - Fax:
Practice Address - Street 1:16659 E 23RD ST S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-1922
Practice Address - Country:US
Practice Address - Phone:816-631-1885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015039584363LF0000X, 363LP2300X
KS77550-072363LP2300X
KS200380880A171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200380880AMedicaid