Provider Demographics
NPI:1568719201
Name:ROSS, MICHELLE (CN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:ROSS
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2915 APPLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-8318
Mailing Address - Country:US
Mailing Address - Phone:916-572-5104
Mailing Address - Fax:888-958-0818
Practice Address - Street 1:2915 APPLEWOOD DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-8318
Practice Address - Country:US
Practice Address - Phone:916-572-5104
Practice Address - Fax:888-958-0818
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist