Provider Demographics
NPI:1770198202
Name:ROSS, ELICIA
Entity Type:Individual
Prefix:
First Name:ELICIA
Middle Name:
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 1:1110 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2912
Mailing Address - Country:US
Mailing Address - Phone:601-738-5820
Mailing Address - Fax:
Practice Address - Street 1:1110 CLAY ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2912
Practice Address - Country:US
Practice Address - Phone:601-738-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker