Provider Demographics
NPI:1689383432
Name:ROSS, NINA MICHELLE
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:MICHELLE
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 1:300 INTERNATIONAL PARKWAY,
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3625
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:937 HILLTOP DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5845
Practice Address - Country:US
Practice Address - Phone:682-208-4394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician