Provider Demographics
NPI:1013536796
Name:ROSS, KIM LOVETT
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LOVETT
Last Name:ROSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 LAWYERS LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-3129
Mailing Address - Country:US
Mailing Address - Phone:706-256-3200
Mailing Address - Fax:
Practice Address - Street 1:919 LAWYERS LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-3129
Practice Address - Country:US
Practice Address - Phone:706-256-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker