Provider Demographics
NPI:1962530535
Name:ROSS, MACHA J (LPN)
Entity type:Individual
Prefix:
First Name:MACHA
Middle Name:J
Last Name:ROSS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TENNESSEE RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37178-4003
Mailing Address - Country:US
Mailing Address - Phone:931-721-3337
Mailing Address - Fax:931-721-3308
Practice Address - Street 1:1330 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TENNESSEE RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37178-4003
Practice Address - Country:US
Practice Address - Phone:931-721-3337
Practice Address - Fax:931-721-3308
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNLPN0000049909OtherNURSING LICENSE