Provider Demographics
NPI:1205147253
Name:ROSS, DEBRA LYNN (LPN)
Entity type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:LYNN
Last Name:ROSS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 MORKEL DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-1842
Mailing Address - Country:US
Mailing Address - Phone:618-466-3173
Mailing Address - Fax:
Practice Address - Street 1:4124 ALBY ST
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4478
Practice Address - Country:US
Practice Address - Phone:618-466-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.076178164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse