Provider Demographics
NPI:1366045775
Name:ROSS, CAROLYN SUE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SUE
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 1:505 GREEN TEAL PL
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:OH
Mailing Address - Zip Code:44839-9163
Mailing Address - Country:US
Mailing Address - Phone:419-433-8957
Mailing Address - Fax:
Practice Address - Street 1:505 GREEN TEAL PL
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:OH
Practice Address - Zip Code:44839-9163
Practice Address - Country:US
Practice Address - Phone:419-433-8957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-18
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
OH5010504712053747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant