Provider Demographics
NPI:1922860857
Name:ROSS, KATRINA NICOLE (BSN, RN, NP-STUDENT)
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:NICOLE
Last Name:ROSS
Suffix:
Gender:F
Credentials:BSN, RN, NP-STUDENT
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:NICOLE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1787 N AVOCET DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5579
Mailing Address - Country:US
Mailing Address - Phone:951-575-5707
Mailing Address - Fax:
Practice Address - Street 1:50 N MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:951-575-5707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT13012198-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program