Provider Demographics
NPI:1487788394
Name:ROSS, SANDRA JENNIE (INDEPENDENT PROVIDER)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:JENNIE
Last Name:ROSS
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4183 STATE ROUTE 73
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-7803
Mailing Address - Country:US
Mailing Address - Phone:937-393-8487
Mailing Address - Fax:
Practice Address - Street 1:4183 STATE ROUTE 73
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-7803
Practice Address - Country:US
Practice Address - Phone:937-393-8487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2662542171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2662542OtherPROVIDER