Provider Demographics
NPI:1336668961
Name:ROSS, MUNTAISHA SHUNQUILL
Entity Type:Individual
Prefix:
First Name:MUNTAISHA
Middle Name:SHUNQUILL
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 1:3718 MAYFAIR LN APT B
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-6574
Mailing Address - Country:US
Mailing Address - Phone:229-364-7308
Mailing Address - Fax:
Practice Address - Street 1:3718 MAYFAIR LANE
Practice Address - Street 2:APT B
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31721
Practice Address - Country:US
Practice Address - Phone:229-364-7308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor