Provider Demographics
NPI:1144622523
Name:GROSS, THERESA (APRN)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:
Last Name:GROSS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 S KY 233
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:KY
Mailing Address - Zip Code:40734-6859
Mailing Address - Country:US
Mailing Address - Phone:606-521-9147
Mailing Address - Fax:
Practice Address - Street 1:121 BISHOP ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1702
Practice Address - Country:US
Practice Address - Phone:606-528-2124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008942363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100345190Medicaid