Provider Demographics
NPI:1669936258
Name:ROSS, MARINA B
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:B
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 1:104 E DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-6350
Mailing Address - Country:US
Mailing Address - Phone:352-431-3940
Mailing Address - Fax:352-431-3173
Practice Address - Street 1:305 SKYLINE DR STE 1
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-4592
Practice Address - Country:US
Practice Address - Phone:352-431-3940
Practice Address - Fax:352-431-3173
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11001032364SP0810X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0810XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Child & Family
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPRN11001032OtherLICENSE