Provider Demographics
NPI:1366845885
Name:ROSS, KARLY KLARISSE
Entity Type:Individual
Prefix:
First Name:KARLY
Middle Name:KLARISSE
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 1:520 E AUGUSTA AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:KS
Mailing Address - Zip Code:67010-2100
Mailing Address - Country:US
Mailing Address - Phone:316-775-5491
Mailing Address - Fax:
Practice Address - Street 1:2821 BROOKSIDE CT
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KS
Practice Address - Zip Code:67010
Practice Address - Country:US
Practice Address - Phone:316-425-0073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator