Provider Demographics
NPI:1063855112
Name:GROSS, DEMETRIA ANN (RN)
Entity type:Individual
Prefix:MRS
First Name:DEMETRIA
Middle Name:ANN
Last Name:GROSS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41045 VISTA WOODS WAY
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-4536
Mailing Address - Country:US
Mailing Address - Phone:586-291-1411
Mailing Address - Fax:
Practice Address - Street 1:41045 VISTA WOODS WAY
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-4536
Practice Address - Country:US
Practice Address - Phone:586-291-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704218611305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service