Provider Demographics
NPI:1124179684
Name:GROSS, MELODI MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MELODI
Middle Name:MARIE
Last Name:GROSS
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:PO BOX 401
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44068-0401
Mailing Address - Country:US
Mailing Address - Phone:440-224-2973
Mailing Address - Fax:
Practice Address - Street 1:14814 FORD RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:OH
Practice Address - Zip Code:44057-9528
Practice Address - Country:US
Practice Address - Phone:440-628-4523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-107145164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse