Provider Demographics
NPI:1205413077
Name:ROSS, LINDA (LPN)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
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:PO BOX 91
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-0091
Mailing Address - Country:US
Mailing Address - Phone:423-437-2404
Mailing Address - Fax:
Practice Address - Street 1:596 PINECREST ROAD
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757
Practice Address - Country:US
Practice Address - Phone:423-437-2404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN79770164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse