Provider Demographics
NPI:1700032026
Name:ROSS, SUSAN ELLEN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:ELLEN
Last Name:ROSS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 MEADOWS AVE
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:TX
Mailing Address - Zip Code:76226-6540
Mailing Address - Country:US
Mailing Address - Phone:210-639-0166
Mailing Address - Fax:
Practice Address - Street 1:709 W LEUDA ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3115
Practice Address - Country:US
Practice Address - Phone:817-926-2511
Practice Address - Fax:817-924-0167
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX612494363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily