Provider Demographics
NPI:1023577947
Name:ROSS, EDDA L (LPN)
Entity Type:Individual
Prefix:
First Name:EDDA
Middle Name:L
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 1:585 DAYTONA PKWY APT 2
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-2061
Mailing Address - Country:US
Mailing Address - Phone:937-530-3611
Mailing Address - Fax:
Practice Address - Street 1:601 ROSAMOND DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-8839
Practice Address - Country:US
Practice Address - Phone:937-530-3611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH071970164W00000X
OHRN461353163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No164W00000XNursing Service ProvidersLicensed Practical Nurse