Provider Demographics
NPI:1760265862
Name:ROSS, SAVANNAH CAMELA
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:CAMELA
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:PO BOX 691
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:IL
Mailing Address - Zip Code:61732-0691
Mailing Address - Country:US
Mailing Address - Phone:309-825-4069
Mailing Address - Fax:
Practice Address - Street 1:208 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:DANVERS
Practice Address - State:IL
Practice Address - Zip Code:61732-9342
Practice Address - Country:US
Practice Address - Phone:309-825-4069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027332363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily