Provider Demographics
NPI:1275128571
Name:ROSS, MANDY L
Entity Type:Individual
Prefix:MISS
First Name:MANDY
Middle Name:L
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 1:8147 35TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SHEYENNE
Mailing Address - State:ND
Mailing Address - Zip Code:58374-9668
Mailing Address - Country:US
Mailing Address - Phone:701-649-6269
Mailing Address - Fax:
Practice Address - Street 1:8147 35TH ST NE
Practice Address - Street 2:
Practice Address - City:SHEYENNE
Practice Address - State:ND
Practice Address - Zip Code:58374-9668
Practice Address - Country:US
Practice Address - Phone:701-649-6269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND58374021213OtherQSP