Provider Demographics
NPI:1417947037
Name:WRIGHT STATE UNIVERSITY STUDENT HEALTH SERVICES
Entity Type:Organization
Organization Name:WRIGHT STATE UNIVERSITY STUDENT HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEATHA
Authorized Official - Middle Name:MAE
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CNP
Authorized Official - Phone:937-775-2552
Mailing Address - Street 1:3640 COLONEL GLENN HWY
Mailing Address - Street 2:051 STUDENT UNION
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45435
Mailing Address - Country:US
Mailing Address - Phone:937-775-2552
Mailing Address - Fax:937-775-2277
Practice Address - Street 1:3640 COLONEL GLENN HWY
Practice Address - Street 2:051 STUDENT UNION
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45435
Practice Address - Country:US
Practice Address - Phone:937-775-2552
Practice Address - Fax:937-775-2277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-238463363LF0000X
OH363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty